Caring electronically for young outpatients who have epilepsy

Did pediatric drug development advance epilepsy treatment in young patients? It is time for new research goals

Modern drugs have changed epilepsy, which affects people of all ages. However, for young people with epilepsy, the framework of drug development has stalled. In the wake of the thalidomide catastrophe, the misconception emerged that for people < 18 years of age drugs, including antiseizure medications (ASMs), need separate proof of efficacy and safety, overall called "pediatric drug development". For ASMs, this has changed to some degree. Authorities now accept that ASMs are effective in < 18 years as well, but they still require "extrapolation of efficacy," as if minors were another species. As a result, some of the pediatric clinical epilepsy research over the past decades was unnecessary. Even more importantly, this has hampered research on meaningful research goals. We do not need to confirm that ASMs work before as they do after the 18^th birthday. Instead, we need to learn how to prevent brain damage in young patients by preventing seizures and optimize ASMs’ uses. Herein we discuss how to proceed in this endeavor.

Autism Spectrum Disorder Parent Report for Outcome Monitoring: A Preliminary Report of Development and Clinical Utility

OBJECTIVE

Children with autism spectrum disorder (ASD) face challenges across many functional domains. A tool that gathers relevant clinical information before visits, emphasizing symptoms that are likely to change over development and inform clinical interventions, could improve health care quality, allowing for more patient-centered and efficient care. This study evaluated the clinical utility and preliminary psychometrics of the ASD Parent Report for Outcome Monitoring (ASD-PROM), a web-based measure assessing competence in core features of ASD, along with the breadth of concerns and comorbidities that frequently co-occur with ASD.

METHODS

An interdisciplinary team drafted the ASD-PROM and made iterative revisions based on parent feedback. Parents of 62 children completed the ASD-PROM before their autism-specialty clinical visit, 53 completed the ASD-PROM twice, and 48 completed the Vineland Adaptive Behavior Scales, Second Edition (Vineland-II) concurrently. Parents (n = 25) and clinicians (n = 13) completed postvisit surveys to assess utility (phase 1). The ASD-PROM was then released for general clinical use (phase 2).

RESULTS

On a Likert scale (1 = very poorly, 10 = very well), parents found that ASD-PROM items described their child's abilities well (median = 8.0; interquartile range [IQR]: 7.0-9.5) and had a positive effect on care (median = 8.0; IQR: 7.0-10.0). Clinicians found the ASD-PROM effective in assessing parent-reported patient abilities (median = 9.0, IQR: 7.0-9.0) and felt the ASD-PROM helped make their care more patient-centered and efficient (both median = 8.0, IQR: 6.0-9.0). Two-week test-retest reliability was acceptable (0.95). ASD-PROM scores correlated positively with scores from similar domains on the Vineland-II (Pearson r 0.30-0.50, medium to large effects).

CONCLUSION

The ASD-PROM is a freely available tool to gather information on developmental and behavioral functioning in children with ASD before autism-specialty clinical visits. Clinical utility and preliminary psychometrics are promising, although limitations (including a low response rate during clinical use and a need for additional in-depth assessments and potential resulting modifications to the tool) remain to be addressed. Ultimately, the ASD-PROM may help promote patient-centered and efficient care for children across a wide range of ages and developmental levels.

Relationship of antiepileptic drugs to generic brittleness in patients with epilepsy

PURPOSE

The purpose of the study was to assess if any antiepileptic drug (AED) was associated with patients being generic brittle (GB) and if any specific AED caused - and was not merely associated with - more frequent switch problems.

METHODS

Chi square and binary logistical regression analysis were performed, using a previously described study in patients with epilepsy who were routinely followed at the University of Maryland epilepsy outpatient clinic in Baltimore, Maryland. Determination of generic brittleness mirrored clinical practice and included patient opinion about generic formulations, usually based on a history of worsened seizures or side effects with prior AED formulation switching. The dataset included a total of 148 patients, who took 30 different AED formulations. Patients collectively took 530 AED formulation products.

RESULTS

Taking lamotrigine immediate release (IR) tablets was associated with a greater probability of being GB and tended to cause more frequent switch problems. Interestingly, six AEDs - Vimpat tablet, carbamazepine IR tablet, phenobarbital (any formulation), gabapentin capsule, Lyrica capsules, and phenytoin (any formulation) - were associated with a reduced probability of being GB, although perhaps not through greater efficacy and tolerability, or better formulation quality. Since tablet and capsule appearance may influence patient perceptions and clinical outcomes, it was observed that the six AEDs less associated with being GB also tended to have fewer generics, and hence possibly lessen treatment uncertainties from the patient perspective. A patient taking more AEDs had significantly increased odds of having a switch problem. An additional observation was that, when a generic was available for their most problematic AED, GB patients took a generic AED only 50% of the time, while not GB patients took a generic AED all the time.

CONCLUSIONS

Taking lamotrigine IR tablets was associated with a greater probability of being GB and tended to cause more frequent switch problems than other AEDs in this cohort of patients. Six AEDs were associated with a reduced probability of being GB. The lower number of different generics for these six drugs may result in greater patient certainty in medication identity, due to greater consistency in medication color, shape, and size, and hence less generic skepticism or generic brittleness. Also, patients taking more AEDs showed increased odds of a switch problem.