Long-term lacosamide retention-Real-world experience at a tertiary epilepsy center in Ireland

Real-world analysis of retention on cenobamate in patients with epilepsy in the United States

BACKGROUND

This retrospective, observational study used US claims data to assess retention rates on cenobamate compared with four branded antiseizure medications (ASMs) in patients with epilepsy.

METHODS

Adults (≥18 years) with prevalent epilepsy (ICD-10 code G40.xx) and ≥ 1 prescription for cenobamate or any of the newer branded ASMs (brivaracetam, eslicarbazepine, lacosamide, or perampanel) between May 1, 2020 and December 31, 2021 were identified from the HealthVerity Marketplace database. At least 360 days of continuous enrollment was required before and after the index date (Day 1 of initiating cenobamate or branded ASM). Patients were followed until cessation of cenobamate or branded ASM or the end of data collection using Kaplan-Meier methods. Retention was compared between cenobamate and the branded ASMs (both as a group and individually) using Chi-square tests.

RESULTS

In total, 4109 patients were included (195 cenobamate; 3914 branded ASMs). A higher proportion of patients in the cenobamate group compared with the branded ASMs group had concurrent focal and generalized epilepsy (65.6% vs 40.0%) and were on ≥ 3 concomitant ASMs (48.2% vs 12.8%) at the index date. Median time to discontinuation (i.e., the time that half the patients discontinued) was not quite reached after 12 months in the cenobamate group (50.3% of patients remained on cenobamate) and was 7.7 months in the branded ASMs group. Retention was significantly higher with cenobamate vs the branded ASMs group (p = 0.04545) and vs the individual ASMs lacosamide (p = 0.03044) and perampanel (p = 0.01558). Twelve-month retention rates (95% confidence intervals) were 50.3% (43.1%-57.0%) for cenobamate, 40.5% (38.9%-42.0%) for branded ASMs overall, 42.3% (38.6%-46.0%) for brivaracetam, 44.1% (39.2%-49.0%) for eslicarbazepine, 39.9% (38.0%-41.8%) for lacosamide, and 36.8% (31.9%-41.8%) for perampanel.

CONCLUSIONS

In this real-world analysis, retention was significantly higher with cenobamate vs a pooled group of four branded ASMs despite a greater frequency of patients in the cenobamate group having characteristics of more difficult-to-treat epilepsy.

Investigation of the efficacy and adverse effects of lacosamide over 36 months

OBJECTIVE

To evaluate the efficacy and retention rate of lacosamide (LCM) over 36 months as a treatment for children and adolescents with focal and generalized epilepsy based on a retrospective study.

METHODS

All patients prescribed LCM as monotherapy and add-on therapy between October 2016 and September 2019 at Jichi Children's Medical Center Tochigi were included in the study. The response rate, retention rate, and adverse effects were calculated.

RESULTS

A total of 126 (female, n = 73) patients of 1.3 to 34.9 years old (median age: 12.8 years; mean ± SD 13.2 ± 6.6 years) received LCM as monotherapy or add-on treatment for focal, generalized, and combined focal and generalized epilepsy. The response rate was 40.5% at 3 months, 40.5% at 6 months, 38.1% at 9 months, 35.7% at 12 months, 25.9% at 24 months, and 29.4% at 36 months. For 34 patients who were observable for 36 months, the retention rate was 70.6% at 3 months, but then gradually declined to 34.8% at 36 months. According to the number of concomitant anti-seizure medications (ASMs), the retention rate was higher in patients receiving <3 ASMs than in those receiving ≥3 ASMs at all observation points. The most common adverse effects were somnolence in 21 patients (16.7%) and dizziness in 5 patients (39.7%).

CONCLUSION

Our response rate was lower and our retention rate was higher in comparison to a previous study that observed patients over 36 months. Further prospective studies in children are required to confirm the response rate and retention rate in patients treated with LCM over 36 months.

Clinical Efficacy and Safety of Lacosamide as an Adjunctive Treatment in Adults With Refractory Epilepsy

Background: Lacosamide (LCM), a novel AED (antiepileptic drug), was used as an adjunctive treatment in patients with partial-onset seizures or without secondary generalization. However, no meta-analysis was performed to evaluate the efficacy of LCM as an adjunctive treatment in post-marketing clinical studies.

Aims: To assess the safety and efficacy of LCM as an adjunctive treatment in adults with refractory epilepsy, a systematic review and meta-analysis of randomized controlled trials (RCTs) and real-world studies were performed.

Methods: All studies were identified from electronic databases. Both RCTs and observational prospective studies were included. Primary outcomes included responder rate, adverse effects (AEs) and withdraw rate. The pooled rates (PR) with their corresponding 95% confidence intervals (CI) were calculated. Publication bias was assessed with Begg's or Egger's tests.

Results: Total 16 studies (3,191 patients) including 5 RCTs and 11 real-word studies were enrolled. The pooled 50% responder rate and seizure-free rate were 48% (95% CI: 0.42, 0.54) and 9% (95% CI: 0.06, 0.11) in all studies, respectively. Subgroup analysis showed that the pooled 50% responder rate were 53% (95% CI: 0.44, 0.62) from observational studies and 38% (95% CI: 0.35, 0.42) from RCTs, respectively; the pooled seizure-free rate were 13% (95% CI: 0.09, 0.18) from observational studies and 4% (95% CI: 0.06, 0.11) from RCTs, respectively. Similar incidence of AEs were reported in real-world studies (0.57, 95% CI: 0.43, 0.72) and RCTs (0.59, 95% CI: 0.42–0.76). Finally, a total of 13% (95%CI: 0.09, 0.16) and 13% (95% CI: 0.08, 0.16) of all patients prescribed with LCM was withdrawn in RCTs and real-world studies, respectively, due to the occurrence of AEs. Furthermore, similar to the 50% responder rate, seizure-free rate, incidence of AEs and withdraw rate were reported at 6-month or at least 12-month of LCM adjunction. Publication bias was not detected in these studies.

Conclusions: Our results revealed that LCM adjunctive therapy even with long-term treatment was efficacious and well tolerated in adults with refractory epilepsy.

Use of Real-World Data and Pharmacometric Modeling in Support of Lacosamide Dosing in Pediatric Patients Under 4 Years of Age

The antiepileptic drug lacosamide (LCM) is approved in the United States and the European Union as monotherapy as well as adjunctive therapy for the treatment of focal seizures in children ≥4 years of age and adults. Using real-world therapeutic drug monitoring data, we performed a pharmacometric analysis for 315 pediatric patients (>1 month to <18 years of age) who received lacosamide as both monotherapy and adjunctive therapy. Population pharmacokinetic modeling was performed using nonlinear mixed-effects modeling with a 1-compartment structural model with linear elimination, where clearance and volume of distribution were allometrically scaled for body weight, with no further need for age-associated maturation functions. A covariate analysis for age, sex, race, and coadministration of other antiepileptic drugs identified phenobarbital and felbamate to significantly increase lacosamide clearance (1.71- and 1.46-fold, respectively). Based on the developed population pharmacokinetic model, simulations were performed in virtual pediatric patients to explore age-associated dose requirements to match lacosamide exposure in patient groups of different age with the exposure achieved in children ≥4 year of age with the weight-based dosing recommendations provided by the US Food and Drug Administration. Based on this approach, our analysis suggested that children ≥3 years of age needed the same dose as recommended by the US Food and Drug Administration for children ≥4 years of age (12 mg/kg/d), while children 1 to 3 years of age may need 13 to 14 mg/kg/d and infants between 1 month and 1 year of age may need 15 to 18 mg/kg/d (based on their actual age) to match the exposure seen in children ≥4 years of age.

The effect of lacosamide on psychiatric comorbidities in patients with epilepsy

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Lacosamide appears to be a low-risk ASM in people with focal epilepsies.

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Lacosamide had a high retention rate in patients with psychiatric comorbidities.

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Lacosamide may provide favorable seizure outcome and improve psychiatric comorbidities in some patients similar to other ASM.

We investigated the efficacy of lacosamide (LCM) polytherapy in improving seizure outcomes and psychiatric symptoms in patients with epilepsy with psychiatric comorbidities. We retrospectively collected data from medical records of outpatients of the Department of Psychiatry of Nishiniigata Chuo Hospital Epilepsy Center in Japan. We extracted data from all patients with epilepsy and psychiatric comorbidities who had been treated with LCM. We evaluated seizure prognosis and changes in psychiatric symptoms after LCM polytherapy. After LCM administration, 19 (47.5%) patients had improvements in seizure outcomes. The other 18 (45%) patients experienced no changes in seizure outcomes, and the remaining 3 (7.5%) patients experienced worse seizure outcomes after LCM polytherapy. LCM administration improved psychiatric symptoms in 21 (52.5%) of the 40 patients; psychiatric symptoms did not change in 14 (35%) patients and worsened in 5 patients (12.5%). There was no significant association between psychiatric and seizure prognoses. LCM polytherapy may have less negative influence on psychiatric comorbidities in patients with epilepsy compared with other antiseizure medications, and may also improve seizure severity. While LCM polytherapy might improve psychiatric symptoms as seizures improve, a small number of patients experienced worsening of psychiatric symptoms despite seizure improvement.

The impact of lacosamide on mood disorders in adult patients with epilepsy: A systematic review

Mood disorders such as depression and anxiety have a high prevalence in adult patients with epilepsy, and their evaluation is crucial in choosing the most appropriate antiepileptic drug (AED) with regard to side effects, which can account for long-term discontinuation, poor compliance, and ultimately, failure of seizure control. While more evidence is provided for older AEDs on their effect on mood changes, newer AEDs such as lacosamide have not yet been extensively studied. We performed a systematic review of the literature available on the impact of lacosamide on mood in adult patients with epilepsy. A literature search on MEDLINE, COCHRANE, Scielo, and Clinicaltrials.gov databases was performed, and articles where mood scales where specifically reported as primary or secondary outcome measures were included. Articles differed greatly in terms of inclusion criteria, concomitant AEDs, seizure reduction control, and outcome measures. If lacosamide is used as add-on, two studies point towards a beneficial effect on depressive and anxiety symptoms, two studies claim no effects on mood, and one reports a positive effect only in patients with major depressive symptoms at baseline. Additional evidence from either retrospective or comparative drug studies indicates no effects of lacosamide on mood. Even though presently, a negative effect on mood seems unlikely, whether lacosamide could exert a beneficial impact on mood remains controversial. Multicenter, randomized, controlled, double-blind studies are needed to assess the impact on lacosamide on mood disorders, given the low evidence level (Class III and IV) of currently available studies.

Clinical experience combined with therapeutic drug monitoring of lacosamide

OBJECTIVE

Lacosamide (LCM) is an antiepileptic drug (AED) with insufficient clinical experience in patients with intellectual disability (ID). They often have more severe epilepsy with comorbidities. The objective was to evaluate the efficacy and tolerability of lacosamide (LCM) in patients with refractory epilepsy with and without ID in a real-life setting, taking drug monitoring (TDM) data into account therapeutic.

METHODS

Retrospectively, we identified 344 patients using LCM from the TDM service covering the majority of the country, at the National Center for Epilepsy in Norway (2013-2018). Clinical and TDM data were available for 132 patients.

RESULTS

Forty-four of the 132 patients (33%) had ID. The retention rate was significantly higher in the ID vs the non-ID group after 1 year (84% vs 68%, P < .05). By combining clinical and TDM data, we demonstrated that 37/38 responding patients had serum concentrations above the lower limit of the reference range (>10 µmol/L), and 16/17 with lower concentrations were non-responders. Mean serum concentration/dose ratios were similar in both groups, 0.06 and 0.07 µmol/L/mg. There were no significant differences regarding efficacy and tolerability. The risk of LCM withdrawal was significantly higher when LCM was added to sodium channel blockers, even if the latter was discontinued.

SIGNIFICANCE

Lacosamide was generally well tolerated in patients with drug-resistant epilepsy, where one third had ID, and in these patients the retention rate was higher. The combination of clinical and TDM data could possibly facilitate LCM therapy in these vulnerable patients.

Adjunctive lacosamide treatment for adult focal-onset epilepsy: focus on comorbid intellectual/developmental disorders and differing responses

Background

Data regarding lacosamide treatment as an adjunctive therapy in patients representative of a focal-onset epilepsy population including those with and without intellectual/developmental disorders (IDDs) are limited.

Purpose

To evaluate the retention rates of lacosamide in focal-onset epilepsy patients with and without IDD.

Patients and methods

We retrospectively reviewed all consecutive electronic and paper medical records of patients diagnosed with focal-onset epilepsy who were treated with lacosamide in two tertiary epilepsy centers.

Results

One hundred and thirty-six patients who met the inclusion criteria were studied. Number of patients with IDD was 46 (33.8%). Median lacosamide dose was 300 mg/day. A total of 39 patients (28.7%) experienced side effects, and 22 of them (16.2%) discontinued lacosamide. The 1-, 2-, and 3-year retention rates of lacosamide in patients with IDD were 68%, 62%, and 53%, respectively. Kaplan–Meier survival analysis showed that the retention rates were significantly lower in patients with IDD when compared to patients without IDD (P=0.04). Cox regression analysis showed that concomitant use of sodium channel blocker antiepileptic drugs (AEDs) was the only independent predictor of retention rate of lacosamide treatment (P=0.03). In the subgroup of patients with IDD, the analysis was performed again and the number of background AEDs was the only predictor for the retention rate of lacosamide (P=0.04).

Conclusion

When compared to patients without IDD, retention rates of lacosamide adjunctive therapy were lower in patients with IDD. However, these rates were higher than the rates suggested with previously registered AEDs including lamotrigine, levetiracetam, and topiramate. Therefore, irrespective of having comorbid IDD, we might suggest that lacosamide is a well-retained drug with a high efficacy profile in patients with focal-onset epilepsy.

Lacosamide-induced excessive laughing in a patient with Lennox-Gastaut syndrome

Lacosamide is one of the third-generation antiseizure drugs that block voltage-gated sodium channels by enhancing slow inactivation. The most common adverse effects of lacosamide include dizziness, headache, nausea, vomiting, diplopia, fatigue, and sedation. Less common side effects include memory impairment, weight gain, rash, and atrioventricular block. In this article, we describe a patient with Lennox–Gastaut syndrome who developed excessive laughing as a rare side effect of lacosamide with complete resolution after discontinuation of the medication. The present case illustrates that excessive laughing may occur as an adverse effect of lacosamide.

The retention of lacosamide in patients with epilepsy and intellectual disability in three specialised institutions

PURPOSE

We describe the effectiveness of lacosamide as adjunctive therapy in patients with epilepsy and an intellectual disability. This information is relevant, as few data exist pertaining to this population with a high prevalence of (intractable) epilepsy.

METHODS

We performed a retrospective study in three specialised institutions. Inclusion criteria were (1) focal onset or symptomatic generalized (2) therapy-resistant epilepsy, (3) intellectual disability and (4) residence in a care-facility for people with intellectual disabilities (PWID). The primary outcome variables were the retention rates of lacosamide, estimated through Kaplan-Meier survival analysis. Secondary outcomes were reported seizure control, side effects and clinical factors influencing discontinuation.

RESULTS

One hundred and thirty-two patients were included. The median retention time of lacosamide in our cohort was four years. The estimated one-, two- and three-year retention rates of lacosamide were 64%, 57% and 56% respectively. Severity of intellectual disability and seizure type did not influence whether lacosamide was continued. In 48.5% of patients, a reduction of seizure activity was reported. Side effects were at least part of the reason for discontinuing treatment in 26.5% of all patients. Common side effects were tiredness/somnolence (in 30.3%), aggression/agitation (24.2%), and instable gait (15.2%). Five deaths during follow-up were considered unlikely to be related to the use of lacosamide. One patient died unexpectedly within two months of treatment onset, probably this was a case of SUDEP.

CONCLUSION

These retention rates of lacosamide in PWID are similar to rates of previously registered anti-epileptic drugs in PWID. Behavioural side effects were noted in a high proportion compared to the general literature on lacosamide. Other side effects were in line with this literature. Lacosamide seems effective and safe for PWID and refractory epilepsy.