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Okazaki S, Kumagai T, Nishiuma S, Iwasaki K, Yamamoto K, Kokubo K, Hayashi H, Nakagawa E. Emergency management of pediatric epileptic seizures in non-hospital settings in Japan. Epilepsy Behav 2024; 158:109914. [PMID: 38970891 DOI: 10.1016/j.yebeh.2024.109914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 05/27/2024] [Accepted: 06/19/2024] [Indexed: 07/08/2024]
Abstract
OBJECTIVE To assess the current management of pediatric epileptic seizures in non-hospital settings and the efficacy of early therapeutic intervention with rescue medication in Japan. METHODS This descriptive cross-sectional study was based on an online survey of caregivers of pediatric patients with epilepsy. The survey consisted of questions regarding seizure frequency and symptoms, the use of rescue medication, and emergency medical care. Statistical analyses were performed to evaluate the association between the time to rescue medication administration and seizure resolution. RESULTS Responses were obtained from 1147 caregivers of pediatric patients with epilepsy. Of the patients described in the study, 98.5 % had been prescribed anti-seizure medication, 95.3 % had more than a few seizures per year, and 90.3 % used rescue medication. The time to seizure resolution was significantly reduced when rescue medication was administered early. Overall, 28.4 % of the patients required emergency transport to hospital, which increased disruption to the lives of caregivers, who returned to their normal activities after an average of 17.2 h. CONCLUSION Emergency transport of patients places a significant burden on caregivers. Earlier administration of rescue medications is associated with a reduction in the need for emergency room visits, which reduces the burden on the patient as well as the caregiver.
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Affiliation(s)
- Shin Okazaki
- Department of Pediatric Neurology, Osaka City General Hospital, Osaka, Japan.
| | | | | | | | | | - Kinya Kokubo
- Healthcare Consulting, Inc., Tokyo, Japan; Faculty of International Political Science and Economics, Nishogakusha University, Tokyo, Japan
| | | | - Eiji Nakagawa
- Department of Epileptology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
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Glauser T, Becker DA, Long L, Detyniecki K, Penovich P, Sirven J, Peters JM, Rabinowicz AL, Carrazana E. Short-Term Impact of Seizures and Mitigation Opportunities. Curr Neurol Neurosci Rep 2024:10.1007/s11910-024-01350-1. [PMID: 38940995 DOI: 10.1007/s11910-024-01350-1] [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] [Accepted: 06/10/2024] [Indexed: 06/29/2024]
Abstract
PURPOSE OF REVIEW The burden of epilepsy is complex and consists of elements directly related to acute seizures as well as those associated with living with a chronic neurologic disorder. The purpose of this systematic review was to characterize short-term burdens of seizures and to explore the potential value of acute treatments to mitigate these burdens apart from reducing the risk of status epilepticus. RECENT FINDINGS A systematic literature search was conducted using PubMed to identify articles published from January 1, 2017, to June 22, 2023, that described short-term burdens and acute treatments of seizures. Primary outcomes included those related to short-term burdens of seizures and the benefits of acute treatments to reduce short-term burdens. Of the 1332 articles identified through PubMed and 17 through other sources, 27 had relevant outcomes and were included in the qualitative synthesis. Seizure emergencies negatively affected short-term quality of life and the ability to conduct normal daily living activities and were associated with physical (injury) and financial (emergency transport, hospitalization) burdens. The use of acute treatment was associated with a rapid return (≤ 1 h) to normal function/self for both patients and caregivers and potentially lower healthcare utilization and costs. Seizure action plans may improve knowledge and comfort with seizure care, empowering patients and caregivers. The short-term burden of seizures can create a substantial negative impact on patients and caregivers. Acute treatments may reduce the short-term burdens of seizures in addition to their well-described role to reduce seizure activity and the risk for status epilepticus.
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Affiliation(s)
- Tracy Glauser
- Comprehensive Epilepsy Center, Cincinnati Children's Hospital, Cincinnati, OH, USA.
| | - Danielle A Becker
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Lucretia Long
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kamil Detyniecki
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | - Joseph Sirven
- Department of Neurology, Mayo Clinic, Scottsdale, AZ, USA
| | - Jurriaan M Peters
- Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Adrian L Rabinowicz
- Neurelis, Inc, San Diego, CA, USA
- Center for Molecular Biology and Biotechnology, Charles E. Schmidt College of Science, Florida Atlantic University, Jupiter, FL, USA
| | - Enrique Carrazana
- Neurelis, Inc, San Diego, CA, USA
- University of Hawaii John A. Burns School of Medicine, Honolulu, HI, USA
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Long L, Reynolds SS, Lewis LS, Webb MA, Epley C, Maturu S. Evaluation of a Seizure Action Plan in an Adult Epilepsy Center. Neurol Clin Pract 2024; 14:e200275. [PMID: 38586237 PMCID: PMC10997209 DOI: 10.1212/cpj.0000000000200275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 01/10/2024] [Indexed: 04/09/2024]
Abstract
Background Seizure action plans (SAPs) provide valuable information for patients to manage seizure emergencies, but are underutilized in adult epilepsy centers. The purpose of this project was to implement a structured SAP for adult patients with epilepsy. Methods A pre/postimplementation design was used. Provider SAP utilization rates were analyzed over a 16-week period. A pre and postimplementation survey assessed participant perceived impact of the SAP on knowledge and comfort associated with managing seizure emergencies. Provider barriers and facilitators were also assessed. Results Average provider SAP utilization rate was 51.45%. A total of 204 participants completed the surveys, which showed a significant increase in knowledge and comfort for all items, p < 0.001. At postsurvey analysis, 98% of participants felt that all patients with epilepsy should have a SAP regardless of seizure burden. Discussion Implementing a structured SAP increased provider utilization and patient and care partner knowledge and comfort of managing seizure emergencies.
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Affiliation(s)
- Lucretia Long
- The Ohio State University Wexner Medical Center (LL, CE, SM), Columbus; Duke University (RSS, LSL, MAW), Durham, NC
| | - Staci S Reynolds
- The Ohio State University Wexner Medical Center (LL, CE, SM), Columbus; Duke University (RSS, LSL, MAW), Durham, NC
| | - Lisa S Lewis
- The Ohio State University Wexner Medical Center (LL, CE, SM), Columbus; Duke University (RSS, LSL, MAW), Durham, NC
| | - Michelle A Webb
- The Ohio State University Wexner Medical Center (LL, CE, SM), Columbus; Duke University (RSS, LSL, MAW), Durham, NC
| | - Crystal Epley
- The Ohio State University Wexner Medical Center (LL, CE, SM), Columbus; Duke University (RSS, LSL, MAW), Durham, NC
| | - Sarita Maturu
- The Ohio State University Wexner Medical Center (LL, CE, SM), Columbus; Duke University (RSS, LSL, MAW), Durham, NC
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Morris GL, Eads P, Tryfon M, Ems D. Seizure clusters, treatment patterns, and healthcare resource utilization in patients with epilepsy: A Wisconsin-based claims analysis. Epilepsy Behav 2024; 157:109867. [PMID: 38824751 DOI: 10.1016/j.yebeh.2024.109867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 05/21/2024] [Accepted: 05/22/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND Seizure clusters are underresearched and associated with adverse outcomes in patients with epilepsy. This study was a noninterventional, retrospective claims-based analysis using the Wisconsin Health Information Organization (WHIO) All-Payer Claims Database to characterize the epilepsy population in Wisconsin, with a focus on prevalence, treatment patterns, and healthcare resource utilization (HCRU) in patients with seizure clusters prior to the introduction of nasal spray rescue medications. This timeframe allows characterization of a historical baseline for future comparisons with newer treatments. METHODS Four cohorts were defined: (1) all-epilepsy (all patients with epilepsy); and subcohorts of: (2) patients receiving a monotherapy antiseizure medication (ASM); (3) patients receiving ASM polytherapy; and (4) patients treated for seizure clusters (ie, those taking rescue medications and ≥ 1 ASM). Primary outcomes were HCRU over a 12-month follow-up period, which were descriptively analyzed. RESULTS Between 2017 and 2019, 16,384 patients were included in the all-epilepsy cohort; 11,688 (71.3 %) were on monotherapy, 3,849 (23.5 %) were on polytherapy, and 526 (3.2 %) were treated for seizure clusters. Twelve-month retentions to the ASM treatments were 46.7 % (7,895/16,904) in the all-epilepsy cohort, and 40.0 % (4,679/11,688) and 40.1 % (1,544/3,849) in the monotherapy and polytherapy subcohorts, respectively. Rescue medication prescriptions were obtained 1,029 times by the 526 patients in the treated seizure cluster subcohort, with infrequent refill rates (mean 1.6-1.9 times/year). A higher proportion of patients in the treated seizure cluster subcohort had epilepsy-related outpatient visits (89.7 %), other visits (71.3 %), and hospitalizations (25.3 %) than patients in the monotherapy (72.2 %, 50.2 %, 19.3 %, respectively) and polytherapy (83.3 %, 63.3 %, 22.8 %, respectively) subcohorts. Mean (standard deviation) all-cause ($114,717 [$231,667]) and epilepsy-related ($76,134 [$204,930]) costs over 12 months were higher in the treated seizure cluster subcohort than the monotherapy ($89,324 [$220,181] and $30,745 [$145,977], respectively) and polytherapy ($101,506 [$152,931] and $49,383 [$96,285], respectively) subcohorts. CONCLUSIONS Patients treated for seizure clusters incurred higher all-cause and epilepsy-related costs and epilepsy-related HCRU than other subcohorts and had infrequent rescue medication refills. The findings of this analysis highlight the need for appropriate treatment for those patients with epilepsy experiencing seizure clusters. The effect of newer rescue medications to alter these findings will be explored in a follow-up study. Regardless, specialist providers with expertise in treating refractory epilepsy and seizure cluster patients may help to reduce the burden of seizure clusters.
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Affiliation(s)
- George L Morris
- Ascension Wisconsin, St. Mary's Hospital, 2301 N Lake Drive, Milwaukee, WI 53211 USA.
| | - Pam Eads
- UCB Pharma, 1950 Lake Park Dr, Smyrna, GA, USA.
| | - Milena Tryfon
- UCB Pharma, Leona Kruczkowskiego 8 00-380, Warszawa, Poland.
| | - Derek Ems
- UCB Pharma, 1950 Lake Park Dr, Smyrna, GA, USA.
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Pina-Garza JE, Chez M, Cloyd J, Hirsch LJ, Kälviäinen R, Klein P, Lagae L, Sankar R, Specchio N, Strzelczyk A, Toledo M, Trinka E. Outpatient management of prolonged seizures and seizure clusters to prevent progression to a higher-level emergency: Consensus recommendations of an expert working group. Epileptic Disord 2024. [PMID: 38813941 DOI: 10.1002/epd2.20243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 04/25/2024] [Accepted: 05/03/2024] [Indexed: 05/31/2024]
Abstract
OBJECTIVE The management of prolonged seizures (PS) and seizure clusters (SC) is impeded by the lack of international, evidence-based guidance. We aimed to develop expert recommendations regarding consensus definitions of PS, SC, and treatment goals to prevent progression to higher-level emergencies such as status epilepticus (SE). METHODS An expert working group, comprising 12 epileptologists, neurologists, and pharmacologists from Europe and North America, used a modified Delphi consensus methodology to develop and anonymously vote on statements. Consensus was defined as ≥75% voting "Agree"/"Strongly agree." RESULTS All group members strongly agreed that termination of an ongoing seizure in as short a time as possible is the primary goal of rapid and early seizure termination (REST) and that an ideal medication for REST would start to act within 2 min of administration to terminate ongoing seizure activity. Consensus was reached on the terminology defining PS (with proposed thresholds of 5 min for prolonged focal seizures and 2 min for prolonged absence seizures and the convulsive phase of bilateral tonic-clonic seizures) and SC (an abnormal increase in seizure frequency compared with the individual patient's usual seizure pattern). All group members strongly agreed or agreed that patients who have experienced a PS should be offered a REST medication, and all patients who have experienced a SC should be offered an acute cluster treatment (ACT). Further, when prescribing a REST medication or ACT, a seizure action plan should be agreed upon in consultation with the patient and caregiver. SIGNIFICANCE The expert working group had a high level of agreement on the recommendations for defining and managing PS and SC. These recommendations will complement the existing guidance for the management of acute seizures, with the possibility of treating them earlier to potentially avoid progression to more severe seizures, including SE.
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Affiliation(s)
| | - Michael Chez
- Sutter Neuroscience Institute, Sacramento, California, USA
| | - James Cloyd
- College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University, New Haven, Connecticut, USA
| | - Reetta Kälviäinen
- University of Eastern Finland and Epilepsy Center Kuopio University Hospital, Member of the European Reference Network EpiCARE, Kuopio, Finland
| | - Pavel Klein
- Mid-Atlantic Epilepsy and Sleep Center, Bethesda, Maryland, USA
| | - Lieven Lagae
- Department Development and Regeneration, Section Paediatric Neurology, Full Member of the European Reference Network EpiCARE, University Hospitals Leuven, Leuven, Belgium
| | - Raman Sankar
- David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Nicola Specchio
- Neurology, Epilepsy and Movement Disorders Unit, Full Member of the European Reference Network EpiCARE, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University and University Hospital Frankfurt, Frankfurt, Germany
| | - Manuel Toledo
- Epilepsy Unit, Neurology Department, Vall d' Hebron University Hospital, Barcelona, Spain
| | - Eugen Trinka
- Department of Neurology, Neurocritical Care and Neurorehabilitation, Christian Doppler Medical Centre, Centre for Cognitive Neuroscience, Member of the European Reference Network EpiCARE, Paracelsus Medical University, Salzburg, Austria
- Neuroscience Institute, Christian Doppler Medical Centre, Centre for Cognitive Neuroscience Salzburg Paracelsus Medical University, Salzburg, Austria
- Karl Landsteiner Institute of Neurorehabilitation and Space Neurology, Salzburg, Austria
- Department of Public Health, Health Services Research, and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
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Chang RSK, Wu RFY, Lo CNR, Li WTV, Wong JKT, Leung WCY, Tsaw M, Li RJ. Utilization and Acceptance of Rapid Epileptic Seizure Termination Therapies by Patients With Epilepsy and Caregivers in Hong Kong. Am J Ther 2024; 31:e197-e200. [PMID: 37233998 DOI: 10.1097/mjt.0000000000001601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- Richard Shek-Kwan Chang
- Division of Neurology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong SAR
| | - Rachel F Y Wu
- Department of Pharmacology and Pharmacy, University of Hong Kong
| | - Cheuk Nam Rachel Lo
- Division of Neurology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong SAR
| | - Wai Tak Victor Li
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong SAR
| | - Janet K T Wong
- Department of Pharmacology and Pharmacy, University of Hong Kong
| | - William C Y Leung
- Division of Neurology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong SAR
| | - Meagan Tsaw
- Division of Neurology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong SAR
| | - Ricardo Jiatu Li
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong SAR
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Penovich PE, Rao VR, Long L, Carrazana E, Rabinowicz AL. Benzodiazepines for the Treatment of Seizure Clusters. CNS Drugs 2024; 38:125-140. [PMID: 38358613 PMCID: PMC10881644 DOI: 10.1007/s40263-023-01060-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2023] [Indexed: 02/16/2024]
Abstract
Patients with epilepsy may experience seizure clusters, which are described by the US Food and Drug Administration (FDA) as intermittent, stereotypic episodes of frequent seizure activity that are distinct from a patient's usual seizure pattern. Untreated seizure clusters may increase the risk for status epilepticus, as well as decrease quality of life and increase burden on patients and care partners. Benzodiazepine therapies are the mainstay for acute treatment of seizure clusters and are often administered by nonmedical care partners outside a healthcare facility. Three rescue therapies are currently FDA-approved for this indication, with diazepam rectal gel being the first in 1997, for patients aged ≥ 2 years. Limitations of rectal administration (e.g., positioning and disrobing the patient, which may affect ease of use and social acceptability; interpatient variation in bioavailability) led to the investigation of the potential for nasal administration as an alternative. Midazolam nasal spray (MDS) was approved by the FDA in 2019 for patients aged ≥ 12 years and diazepam nasal spray (DNS) in 2020 for patients aged ≥ 6 years; these two intranasal therapies have differences in their formulations [e.g., organic solvents (MDS) vs. Intravail and vitamin E for absorption and solubility (DNS)], effectiveness (e.g., proportion of seizure clusters requiring only one dose), and safety profiles. In clinical studies, the proportion of seizure clusters for which only one dose of medication was used varied between the three approved rescue therapies with the highest single-dose rate for any time period for DNS; however, although studies for all three preparations enrolled patients with highly intractable epilepsy, inclusion and exclusion criteria varied, so the three cannot be directly compared. Treatments that have been used off-label for seizure clusters in the USA include midazolam for injection as an intranasal spray (indicated for sedation/anxiolysis/amnesia and anesthesia) and tablet forms of clonazepam (indicated for treatment for seizure disorders) and lorazepam (indicated for anxiety). In the European Union, buccal and intranasal midazolam are used for treating the indication of prolonged, acute convulsive seizures and rectal diazepam solution for the indication of epileptic and febrile convulsions; duration of effectiveness for these medications for the treatment of seizure clusters has not been established. This paper examines the literature context for understanding seizure clusters and their treatment and provides effectiveness, safety, and administration details for the three FDA-approved rescue therapies. Additionally, other medications that are used for rescue therapy in the USA and globally are discussed. Finally, the potential benefits of seizure action plans and candidates for their use are addressed. This paper is intended to provide details about the unique characteristics of rescue therapies for seizure clusters to help clarify appropriate treatment for individual patients.
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Affiliation(s)
| | - Vikram R Rao
- University of California, San Francisco, CA, USA
| | - Lucretia Long
- Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Enrique Carrazana
- Neurelis, Inc., San Diego, CA, USA
- John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
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Wheless JW, Gidal B, Rabinowicz AL, Carrazana E. Practical Questions About Rescue Medications for Acute Treatment of Seizure Clusters in Children and Adolescents with Epilepsy in the USA: Expanding Treatment Options to Address Unmet Needs. Paediatr Drugs 2024; 26:49-57. [PMID: 37902940 PMCID: PMC10769986 DOI: 10.1007/s40272-023-00601-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2023] [Indexed: 11/01/2023]
Abstract
Epilepsy is a common pediatric neurological condition, affecting approximately 470,000 children in the USA and having a prevalence of 0.9% in the global population of approximately 2.6 billion children. Epilepsy is associated with disruptions in several areas of a child's life, including medical burden, quality of life, cognitive outcomes, and higher risk of mortality. Additionally, some pediatric patients may experience acute seizure emergencies such as seizure clusters (also called acute repetitive seizures), which are intermittent increases in seizure activity that differ from the patient's usual seizure pattern and may occur despite daily antiseizure drug administration. Seizure clusters increase a patient's risk for status epilepticus and emergency room visits. Benzodiazepines are the main category of drugs used as acute seizure therapies for seizure clusters. This narrative review provides a practical discussion of care for pediatric patients with epilepsy and seizure clusters exploring such topics as details about the US Food and Drug Administration-approved acute seizure therapies, safety and ease of use of these medications, benefits of seizure action plans to help ensure optimal treatment, and considerations for transitioning a pediatric patient with acute seizure therapy to adult healthcare management.
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Affiliation(s)
- James W Wheless
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, 38105, USA.
| | - Barry Gidal
- School of Pharmacy, University of Wisconsin-Madison, Madison, WI, USA
| | | | - Enrique Carrazana
- John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
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Egenasi CK, Moodley AA, Steinberg WJ, Joubert G. Experience of the new seizure diary in the Free State and Northern Cape. S Afr Fam Pract (2004) 2023; 65:e1-e11. [PMID: 37265139 PMCID: PMC10483308 DOI: 10.4102/safp.v65i1.5736] [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: 03/01/2023] [Revised: 04/05/2023] [Accepted: 04/06/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND Epilepsy is a neurological disease affecting adults and children globally. A seizure diary is one of the self-management tools for tracking seizures. This study aims to ascertain the experience of a new seizure diary by persons completing the diary in the Free State and Northern Cape of South Africa. METHODS Adult patients with epilepsy attending Universitas Academic Hospital epilepsy clinic in Bloemfontein, clinics in Kimberley and the casualty department of Kimberley hospital (Robert Mangaliso Sobukwe hospital) received a new seizure diary. After using the diary for 6 months, participants (patients, relatives or caregivers) completed a questionnaire. RESULTS A total of 139 epilepsy patients received a new seizure diary; 67 previously diary-unexposed participants and 33 participants who had previous exposure to a seizure diary. The majority of participants, namely 91% of previously diary-unexposed and 84.9% of participants who had previous exposure to the seizure diary, understood the new seizure diary. Participants who had previous exposure to a seizure diary were predominantly very positive about the new diary because it had more information. However, 21.2% indicated that they preferred the old one because it was easier to complete. CONCLUSION Patients, caregivers or relatives from both groups used the new seizure diary and provided important information about their experience with the new diary. Despite a few complaints about using the new diary, most participants who had previous exposure to a seizure diary preferred the new seizure diary.Contribution: This study explored participants' opinions of the new seizure diary.
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Affiliation(s)
- Chika K Egenasi
- Department of Family Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein.
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Cui C, Li S, Chen W, Zhou H, Zheng X. Chinese families' knowledge, attitudes, and practices regarding seizure management for children with epilepsy: a mixed-methods study. Front Public Health 2023; 11:1081720. [PMID: 37255754 PMCID: PMC10225546 DOI: 10.3389/fpubh.2023.1081720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 04/17/2023] [Indexed: 06/01/2023] Open
Abstract
Objective This study aimed to examine Chinese families' knowledge, attitudes, and practices regarding the management of acute seizures (AS) that occur outside the hospital in children with epilepsy (CWE) and factors that influence AS. Design A mixed-methods sequential explanatory study was conducted, which was integrated at the design and methods levels. In phase 1, a questionnaire was developed for this study, and a family functioning assessment was administered from Nov 2021 to Apr 2022. Multivariate logistic regression was used to analyze the knowledge, attitudes, and practices (KAP) and factors that influence AS. In phase 2, family caregivers (FCGs) were recruited from Jul to Aug 2022 to participate in a qualitative exploration, using semi-structured interviews and a combination of inductive and deductive methods. Setting The setting was five children's specialty hospitals in different regions of China. Participants The participants were FCGs of CWE. A total of 645 participants were included in the quantitative phase, and 15 FCGs (eight parents, five grandparents, and two others) were recruited for the qualitative phase. Results The FCGs' average total KAP score for AS management was 66.23 ± 15.12, with 45.42% of FCGs having a low level. Univariate and multivariate regression analyses showed that demographic factors, disease characteristics, and family function significantly predicted family management of AS. The three most salient themes and eight sub-themes from phase 2 were explored. The quantitative and qualitative databases were analyzed separately and combined through integration, and a conceptual model was constructed based on the individual and family self-management theory (IFSMT); the model consisted of context, knowledge, self-regulation, and promotion factors. Conclusion Chinese families have a positive attitude toward the management of out-of-hospital AS in CWE, but lack practice and related knowledge. AS management for CWE families was associated with the demographic characteristics of FCGs, epilepsy, and family characteristics. The research findings expand the existing application requirements of an Acute Seizure Action Plan and patient safety. Our results also indicate a pressing need for localized development of AS emergency medicine in family medicine, the establishment of auxiliary information systems, the utilization of caregivers' positive psychological resources, and improvements in family function for intergenerational care.
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Affiliation(s)
- Cui Cui
- National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Department of Nursing Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Shuangzi Li
- National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Neurology Department of Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Wenjin Chen
- National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Neurology Department of Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Hengyu Zhou
- School of Nursing, Chongqing Medical University, Chongqing, China
| | - Xianlan Zheng
- National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Department of Nursing Children's Hospital of Chongqing Medical University, Chongqing, China
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11
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Leviton A, Patel AD, Loddenkemper T. Self-management education for children with epilepsy and their caregivers. A scoping review. Epilepsy Behav 2023; 144:109232. [PMID: 37196451 DOI: 10.1016/j.yebeh.2023.109232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 05/19/2023]
Abstract
Self-management education programs have been highly successful in preparing people to manage medical conditions with recurring events. A detailed curriculum for epilepsy patients, and their caretakers, is lacking. Here we assess what is available for patients who have disorders with recurring events and offer an approach to developing a potential self-care curriculum for patients with seizures and their caregivers. Among the anticipated components are a baseline efficacy assessment and training tailored to increasing self-efficacy, medication compliance, and stress management. Those at risk of status epilepticus will also need guidance in preparing a personalized seizure action plan and training in how to decide when rescue medication is appropriate and how to administer the therapy. Peers, as well as professionals, could teach and provide support. To our knowledge, no such programs are currently available in English. We encourage their creation, dissemination, and widespread use.
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Affiliation(s)
- Alan Leviton
- Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Anup D Patel
- Nationwide Children's Hospital, 700 Childrens Drive, Columbus, OH 43205, USA.
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Orlandi N, d'Orsi G, Pauletto G, Nilo A, Sicurella L, Pescini F, Giglia F, Labate A, Laganà A, Renna R, Cavalli SM, Zummo L, Coletti Moja M, Vollono C, Sabetta A, Ranzato F, Zappulla S, Audenino D, Miniello S, Nazerian P, Marino D, Lattanzi S, Piccioli M, Estraneo A, Zini A, Servo S, Giovannini G, Meletti S, Bianchini D, Contardi S, Fasolino A, Fiore GM, Foschi N, Giordano A, Laisa P, Lo Coco D, Maccora S, Magaudda A, Panebianco M, Merli E, Piccirillo G, Pugnaghi M, Ramacciotti L, Vaudano AE, Vitale G, Zaniboni A. A retrospective multicentric study on the effectiveness of intravenous brivaracetam in seizure clusters: Data from the Italian experience. Seizure 2023; 108:72-80. [PMID: 37104972 DOI: 10.1016/j.seizure.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 04/29/2023] Open
Abstract
OBJECTIVE Nearly half of people with epilepsy (PWE) are expected to develop seizure clusters (SC), with the subsequent risk of hospitalization. The aim of the present study was to evaluate the use, effectiveness and safety of intravenous (IV) brivaracetam (BRV) in the treatment of SC. METHODS Retrospective multicentric study of patients with SC (≥ 2 seizures/24 h) who received IV BRV. Data collection occurred from January 2019 to April 2022 in 25 Italian neurology units. Primary efficacy outcome was seizure freedom up to 24 h from BRV administration. We also evaluated the risk of evolution into Status Epilepticus (SE) at 6, 12 and 24 h after treatment initiation. A Cox regression model was used to identify outcome predictors. RESULTS 97 patients were included (mean age 62 years), 74 (76%) of whom had a history of epilepsy (with drug resistant seizures in 49% of cases). BRV was administered as first line treatment in 16% of the episodes, while it was used as first or second drug after benzodiazepines failure in 49% and 35% of episodes, respectively. On the one hand, 58% patients were seizure free at 24 h after BRV administration and no other rescue medications were used in 75 out of 97 cases (77%) On the other hand, SC evolved into SE in 17% of cases. A higher probability of seizure relapse and/or evolution into SE was observed in patients without a prior history of epilepsy (HR 2.0; 95% CI 1.03 - 4.1) and in case of BRV administration as second/third line drug (HR 3.2; 95% CI 1.1 - 9.7). No severe treatment emergent adverse events were observed. SIGNIFICANCE In our cohort, IV BRV resulted to be well tolerated for the treatment of SC and it could be considered as a treatment option, particularly in case of in-hospital onset. However, the underlying etiology seems to be the main outcome predictor.
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Affiliation(s)
- Niccolò Orlandi
- Department of Biomedical, Metabolic and Neural Sciences, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy; Neurology department, OCB Hospital, AOU Modena, Italy
| | - Giuseppe d'Orsi
- Neurology Unit, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo (Foggia), Italy
| | - Giada Pauletto
- Neurology Unit, Department of Neurosciences, Santa Maria della Misericordia University Hospital, ASUFC, Udine, Italy
| | - Annacarmen Nilo
- Clinical Neurology Unit, Department of Neurosciences, Santa Maria della Misericordia University Hospital, ASUFC, Udine, Italy
| | | | | | - Francesca Giglia
- Neurology Division with Stroke Unit, "San Giovanni di Dio" Hospital, Agrigento
| | - Angelo Labate
- Neurophysiopatology and Movement Disorders Clinic, Regional Epilepsy Centre, University of Messina, Italy
| | - Angelina Laganà
- Neurophysiopatology and Movement Disorders Clinic, Regional Epilepsy Centre, University of Messina, Italy
| | - Rosaria Renna
- Neurological Clinic and Stroke Unit - "A. Cardarelli" Hospital, Naples, Italy
| | | | - Leila Zummo
- Neurology and Stroke Unit, P.O. ARNAS-Civico, Palermo, Italy
| | | | - Catello Vollono
- Department of Geriatrics, Neurosciences and Orthopedics, Unit of Neurophysiopatology, IRCSS Policlinico Universitario Agostino Gemelli Catholic University, Rome, Italy
| | - Annarita Sabetta
- Epilepsy Centre - S.C. Neurologia Universitaria, Policlinico Riuniti, Foggia, Italy
| | | | | | | | - Stefania Miniello
- Neurology and Stroke Unit, AORN "Sant'Anna E San Sebastiano", Caserta, Italy
| | - Peiman Nazerian
- Department of Emergency Medicine, Careggi University Hospital, Florence, Italy
| | - Daniela Marino
- Epilepsy Center, Neurology Unit, Department of Cardio-neuro-vascular Sciences, San Donato Hospital, Arezzo, Italy
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | | | - Anna Estraneo
- Neurology Unit and Stroke Unit, Santa Maria della Pietà Hospital, Nola, Italy
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Serena Servo
- Neurology Unit, Santa Croce Hospital, Cuneo, Italy
| | | | - Stefano Meletti
- Department of Biomedical, Metabolic and Neural Sciences, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy; Neurology department, OCB Hospital, AOU Modena, Italy.
| | | | - Sara Contardi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Alessandra Fasolino
- Neurological Clinic and Stroke Unit - "A. Cardarelli" Hospital, Naples, Italy
| | | | - Nicoletta Foschi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | | | | | - Daniele Lo Coco
- Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Simona Maccora
- Neurology and Stroke Unit, P.O. ARNAS-Civico, Palermo, Italy
| | - Adriana Magaudda
- Epilepsy Center, Department of Clinical and Experimental Medicine, University of Messina, Italy
| | | | - Elena Merli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Giovanni Piccirillo
- Neurology and Stroke Unit, AORN "Sant'Anna E San Sebastiano", Caserta, Italy
| | | | | | - Anna Elisabetta Vaudano
- Department of Biomedical, Metabolic and Neural Sciences, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy; Neurology department, OCB Hospital, AOU Modena, Italy
| | | | - Anna Zaniboni
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
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Krauss GL, Elizebath R, Mwendaweli N. Seizure Rescue Therapies: Comparing Approved and Commonly Used Benzodiazepine Formulations. Neurotherapeutics 2023; 20:758-766. [PMID: 36928590 PMCID: PMC10275833 DOI: 10.1007/s13311-023-01359-3] [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] [Accepted: 02/17/2023] [Indexed: 03/18/2023] Open
Abstract
Acute seizure therapies given out of the hospital are important for interrupting acute repetitive and prolonged seizures and preventing hospitalization. These vary in their administration routes, indications for children and adults, pharmacologic profiles, and efficacy. We reviewed and compared the uses of current formulations available to treat acute seizures, including newly released intranasal (IN) benzodiazepines and older formulations which are widely used for interrupting seizures.
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Affiliation(s)
- Gregory L Krauss
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
| | - Reena Elizebath
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Naluca Mwendaweli
- Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia
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Rescue Medications for Acute Repetitive Seizures. Curr Treat Options Neurol 2023. [DOI: 10.1007/s11940-023-00746-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
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Goldenholz DM, Westover MB. Flexible realistic simulation of seizure occurrence recapitulating statistical properties of seizure diaries. Epilepsia 2023; 64:396-405. [PMID: 36401798 PMCID: PMC9905290 DOI: 10.1111/epi.17471] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 11/12/2022] [Accepted: 11/17/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE A realistic seizure diary simulator is currently unavailable for many research needs, including clinical trial analysis and evaluation of seizure detection and seizure-forecasting tools. In recent years, important statistical features of seizure diaries have been characterized. These include (1) heterogeneity of individual seizure frequencies, (2) the relation between average seizure rate and standard deviation, (3) multiple risk cycles, (4) seizure clusters, and (5) limitations on inter-seizure intervals. The present study unifies these features into a single model. METHODS Our approach, Cyclic Heterogeneous Overdispersed Clustered Open-source L-relationship Adjustable Temporally limited E-diary Simulator (CHOCOLATES) is based on a hierarchical model centered on a gamma Poisson generator with several modifiers. This model accounts for the aforementioned statistical properties. The model was validated by simulating 10 000 randomized clinical trials (RCTs) of medication to compare with 23 historical RCTs. Metrics of 50% responder rate (RR50) and median percent change (MPC) were evaluated. We also used CHOCOLATES as input to a seizure-forecasting tool to test the flexibility of the model. We examined the area under the receiver-operating characteristic (ROC) curve (AUC) for test data with and without cycles and clusters. RESULTS The model recapitulated typical findings in 23 historical RCTs without the necessity of introducing an additional "placebo effect." The model produced the following RR50 values: placebo: 17 ± 4%; drug 38 ± 5%; and the following MPC values: placebo: 13 ± 6%; drug 40 ± 4%. These values are similar to historical data: for RR50: placebo, 21 ± 10%, drug: 43 ± 13%; and for MPC: placebo: 17 ± 10%, drug: 41 ± 11%. The seizure forecasts achieved an AUC of 0.68 with cycles and clusters, whereas without them the AUC was 0.51. SIGNIFICANCE CHOCOLATES represents the most realistic seizure occurrence simulator to date, based on observations from thousands of patients in different contexts. This tool is open source and flexible, and can be used for many applications, including clinical trial simulation and testing of seizure-forecasting tools.
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Affiliation(s)
- Daniel M. Goldenholz
- Dept. of Neurology, Beth Israel Deaconess Medical Center, Boston 02215 MA
- Dept. of Neurology, Harvard Medical School, Boston 02215 MA
| | - M. Brandon Westover
- Dept. of Neurology, Beth Israel Deaconess Medical Center, Boston 02215 MA
- Dept. of Neurology, Harvard Medical School, Boston 02215 MA
- Dept. of Neurology, Massachusetts General Hospital, Boston 02114 MA
- McCance Center for Brain Health, Boston, 02114 MA
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16
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Egenasi CK, Moodley AA, Steinberg WJ, Joubert G. The perceptions and attitudes of patients with epilepsy to the use of a seizure diary, South Africa. S Afr Fam Pract (2004) 2023; 65:e1-e7. [PMID: 36744483 PMCID: PMC9983296 DOI: 10.4102/safp.v65i1.5503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 07/08/2022] [Accepted: 07/10/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Epilepsy is responsible for a significant proportion of the world's disease burden, affecting around 50 million people globally. A seizure diary is a self-management tool for epilepsy focusing on self-monitoring, tracking seizures and other symptoms. This study aimed to determine the perceptions and attitudes to the seizure diary in patients with epilepsy in the Free State and Northern Cape of South Africa. METHODS This cross-sectional survey method included adult patients with epilepsy attending Universitas Academic Hospital Specialist Epilepsy Clinic in Bloemfontein and local clinics in Kimberley (City, Beaconsfield and Betty Gatsewe), as well as the casualty department of Kimberley hospital (Robert Mangaliso Sobukwe Hospital). The Kimberley patients were diary-unexposed, while the Bloemfontein patients were patients who had previous exposure to the seizure diary. RESULTS A total of 182 patients with epilepsy were recruited for the study, of whom 65 were patients who had previous exposure to the seizure diary, and 117 were unexposed. In the patients who had previous exposure to the seizure diary, 64 (98.5%) found the diary useful, but 15 (23.1%) reported having various challenges with using the seizure diary. Almost all of the patients who had previous exposure to the seizure diary, 64 (98.5%), were willing to continue to use the diary, while 112 (95.7%) of the diary-unexposed patients were also willing to use the diary. CONCLUSION Information from some patients using the diary confirms various challenges with its use; however, most patients support the continued usage of the diary.
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Affiliation(s)
- Chika K. Egenasi
- Department of Family Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| | - Anandan A. Moodley
- Department of Neurology, University of KwaZulu-Natal, Durban, South Africa
| | - Wilhelm J. Steinberg
- Department of Family Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| | - Gina Joubert
- Department of Biostatistics, School of Biomedical Sciences, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
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Meng TC, Szaflarski JP, Chen L, Brunnert M, Campos R, Van Ess P, Pullman WE, Fakhoury T. Psychosocial outcomes of repeated treatment of seizure clusters with midazolam nasal spray: Results of a phase 3, open-label extension trial. Epilepsy Behav 2023; 138:108989. [PMID: 36410152 DOI: 10.1016/j.yebeh.2022.108989] [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: 09/01/2022] [Revised: 10/25/2022] [Accepted: 11/01/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate treatment satisfaction, level of anxiety, confidence about traveling with midazolam nasal spray (MDZ-NS), and health-related quality of life in patients with seizure clusters and their caregivers after repeated, intermittent use of MDZ-NS in the outpatient setting. METHODS We analyzed the psychosocial outcome data from a phase 3, open-label extension trial (ARTEMIS-2; P261-402; NCT01529034) in patients 12 years of age and older with seizure clusters on a stable regimen of antiseizure medications. Caregivers administered MDZ-NS 5 mg when patients experienced a seizure cluster. A second dose could be given if seizures did not terminate within 10 min or recurred from 10 min to 6 h. Treatment Satisfaction Questionnaire for Medication (TSQM), the Intranasal Therapy Impact Questionnaire (ITIQ), and the Short Form-12 Health Survey version 2 (SF-12v2) were self-administered by patients and/or caregivers at prespecified visits. RESULTS Of the one hundred and seventy-five patients enrolled in ARTEMIS-2, 161 (92.0%) received ≥ 1 dose of MDZ-NS and had a post-treatment seizure-related assessment and were included in the Efficacy Evaluable Set in this analysis, with a total of 1,998 treated seizure clusters over a median duration of 16.8 months. All TSQM scales showed improvement from the baseline of the double-blind ARTEMIS-1 trial (NCT01390220) to the last visit in ARTEMIS-2, indicating greater satisfaction with MDZ-NS across all domains, with a mean change from baseline of 8.8, 6.1, 4.3, and 6.2 for effectiveness (n = 135), side effects (n = 139), convenience (n = 139), and global satisfaction (n = 138), respectively. Change from baseline in TSQM scores generally increased with repeated MDZ-NS use. In both patients and caregivers, anxiety generally lessened with repeated MDZ-NS use, with a mean improvement in ITIQ scores in patients' anxiety since receiving MDZ-NS from 2.5 (n = 138) to 3.5 (n = 145) from visit 1 to the last visit (and from 2.6 [n = 156] to 3.6 [n = 160] for caregivers), respectively. From visit 1 (screening and enrollment in ARTEMIS-2) to visit 10 (after 16 seizure cluster episodes treated with MDZ-NS), the proportions of patients and caregivers who answered "strongly agree" or "agree" for confidence about traveling with an intranasal spray remained ≥ 79% and generally increased over repeated MDZ-NS use. Small positive mean changes in SF-12v2 scores from baseline to the last visit were observed in both patients and caregivers, respectively, for the domains of physical functioning (0.9, 1.1), role-physical (2.4, 0.3), bodily pain (1.7, 0.3), general health (0.6, 1.2), and role-emotional (2.1, 0.3), and in the physical health component (1.6, 1.0). CONCLUSION Patients and caregivers perceived MDZ-NS favorably, with improvement from baseline on perceived effectiveness, side effects, convenience, and global satisfaction in the TSQM. This is supported by progressively lower anxiety and higher confidence levels about traveling with MDZ-NS over repeated intermittent use in the ITIQ. The positive mean changes observed in SF-12v2 scores from baseline to the last visit were small in magnitude. Limitations of this exploratory analysis include the open-label trial design and that these questionnaires have not been directly validated in epilepsy to identify clinically important changes; however, this does not mean these findings are not clinically meaningful. Overall, MDZ-NS is a socially acceptable drug device for outpatient treatment of seizure clusters that has the potential to improve quality of life and overall independence.
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Affiliation(s)
- Tze-Chiang Meng
- Proximagen LLC, 605 Highway 169 N, Suite 240, Plymouth, MN 55441, USA.
| | - Jerzy P Szaflarski
- Departments of Neurology, Neurobiology, and Neurosurgery, Comprehensive Neuroscience Center, University of Alabama at Birmingham Heersink School of Medicine, 1719 6th Ave South, CIRC 312, Birmingham, AL 35294, USA.
| | - Linda Chen
- UCB Pharma, 1950 Lake Park Dr SE, Smyrna, GA 30080, USA.
| | - Marcus Brunnert
- UCB Pharma, Alfred-Nobel-Straße 10, 40789 Monheim am Rhein, Germany.
| | - Rita Campos
- UCB Pharma, 1950 Lake Park Dr SE, Smyrna, GA 30080, USA.
| | - Peter Van Ess
- Proximagen LLC, 605 Highway 169 N, Suite 240, Plymouth, MN 55441, USA.
| | - William E Pullman
- Proximagen LLC, 605 Highway 169 N, Suite 240, Plymouth, MN 55441, USA.
| | - Toufic Fakhoury
- St. Joseph Health System, 1401 Harrodsburg Road, Suite B-280, Lexington, KY 40504, USA.
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Jafarpour S, Fong MWK, Detyniecki K, Khan A, Jackson-Shaheed E, Wang X, Lewis S, Benjamin R, Gaínza-Lein M, O'Bryan J, Hirsch LJ, Loddenkemper T. Prevalence and Predictors of Seizure Clusters in Pediatric Patients With Epilepsy: The Harvard-Yale Pediatric Seizure Cluster Study. Pediatr Neurol 2022; 137:22-29. [PMID: 36208614 DOI: 10.1016/j.pediatrneurol.2022.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 08/30/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Determine the prevalence of seizure clusters (two or more seizures in six hours), use of rescue medications, and adverse outcomes associated with seizure clusters in pediatric patients with a range of epilepsy severities, and identify risk factors predictive of seizure clusters. METHODS Prospective observational two-center study, including phone call and seizure diary follow-up for 12 months in patients with epilepsy aged one month to 18 years. We classified patients into three risk groups based on seizures within the prior year: high, seizure cluster (two or more seizures within one day); intermediate, at least one seizure but no days with two or more seizures; low, no seizures. RESULTS One-third (32.3%; high risk, 72.4%; intermediate risk, 30.4%; low risk, 3.1%) of 297 patients had a seizure cluster during the study, including half (46.2%) of the patients with active seizures at baseline (intermediate- and high-risk groups combined). Emergency room visits or injuries were no more likely due to a seizure cluster than an isolated seizure. Rescue medications were utilized in 15.8% of patients in the high-risk group and 19.2% in the intermediate-risk group. History of status epilepticus (adjusted odds ratio [aOR], 2.13; confidence interval [CI], 1.09 to 4.16]), seizure frequency greater than four per month (aOR, 4.27; CI, 1.92 to 9.50), and high-risk group status (aOR, 6.42; CI, 2.97 to 13.87) were associated with greater odds of seizure cluster. CONCLUSIONS Seizure clusters are common in pediatric patients with epilepsy. High seizure frequency was the strongest predictor of clusters. Rescue medications were underutilized. Future studies should evaluate the applicability and effectiveness of these medications for optimization of pediatric seizure cluster treatment and reduction of seizure-related emergency department visits, injuries, and mortality.
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Affiliation(s)
- Saba Jafarpour
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Neurology, Children's Hospital of Los Angeles, Los Angeles, California
| | - Michael W K Fong
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut; TY Nelson Department of Neurology, The Children's Hospital at Westmead, Sydney, Australia; Westmead Comprehensive Epilepsy Unit, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Kamil Detyniecki
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut; Comprehensive Epilepsy Center, Department of Neurology, University of Miami, Miami, Florida
| | - Ambar Khan
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut; Larkin Community Hospital, South Miami, Florida
| | - Ebony Jackson-Shaheed
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut
| | - Xiaofan Wang
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Samuel Lewis
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Robert Benjamin
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Marina Gaínza-Lein
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Instituto dr Pediatria, Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Jane O'Bryan
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut
| | - Lawrence J Hirsch
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
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Asadi-Pooya AA, Hosseini SA. Seizure rescue medications are missing from in-flight medical emergency kits. Epilepsy Behav 2022; 137:108976. [PMID: 36370544 DOI: 10.1016/j.yebeh.2022.108976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE We aimed to inquire whether any seizure rescue medications are included in the in-flight medical emergency kits of the main airlines in the world. This data could help the airline authorities update their strategies in light of any shortcomings. METHODS First, we identified ten major airlines in the world. Then, we searched the Google engine with the following keywords: "name of the airline" and "in-flight medical emergency" or "first aid kit" or "emergency kit". In case there was no information on the web, we emailed the airlines and inquired about the contents of their in-flight medical emergency kits. We also investigated some of the major aviation organizations' websites [i.e., Aerospace Medical Association (AsMA), International Civil Aviation Organization (ICAO), and International Air Transport Association (IATA)]. RESULTS None of the major airlines were equipped with easily applicable seizure rescue medications (i.e., buccal midazolam, a nasal spray of midazolam, or intranasal diazepam). The AsMA and ICAO recommend including injectable sedative anticonvulsant drugs in the in-flight medical emergency kits without any further specifications. The IATA does not provide specific recommendations for including seizure rescue medications in the in-flight medical emergency kits. CONCLUSION A seizure is a significant in-flight medical emergency event. The use of easily applicable seizure rescue medications during prolonged or repeated seizures is significantly associated with fewer sequelae for the affected person. Easily applicable seizure rescue medications should be included in the in-flight medical emergency kits, and the cabin crew should receive training on how and when to use them.
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Affiliation(s)
- Ali Akbar 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.
| | - Seyed Ali Hosseini
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
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Egenasi CK, Moodley AA, Steinberg WJ, Adefuye AO. Current norms and practices in using a seizure diary for managing epilepsy: A scoping review. S Afr Fam Pract (2004) 2022; 64:e1-e9. [PMID: 36226950 PMCID: PMC9575367 DOI: 10.4102/safp.v64i1.5540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 07/22/2022] [Accepted: 07/24/2022] [Indexed: 11/07/2022] Open
Abstract
Background Epilepsy is a chronic and debilitating condition affecting people of all ages in many nations. Healthcare practitioners look for effective ways to track patients’ seizures, and a seizure diary is one of the methods used. This scoping review sought to identify current norms and practices for using seizure diaries to manage epilepsy. Method A scoping review was performed by screening relevant studies and identifying themes, categories and subcategories. Results A total of 1125 articles were identified from the database; 46 full-text articles were assessed for eligibility, of which 23 articles were selected. The majority (48%) of the studies were prospective studies. The majority (65%) of the articles were studies conducted in the United States. The themes identified were types of seizure diaries used in clinical practice, contents and structure of a standardised seizure diary, the use and efficacy of seizure diaries in medicine and challenges relating to using a seizure diary for patient management. Conclusion The study revealed that a seizure diary remains a relevant tool in managing epilepsy. The two forms of diaries in use are electronic and paper-based diaries. The high cost of data and the expensive devices required to access electronic diaries make it unsuitable in a resource-limited setting. Despite its disadvantages, imperfections and inadequacies, the paper-based diary is still relevant for managing patients with epilepsy in resource-limited settings. Contribution This study reviewed the literature to find the current norms and practices in using seizure diaries. The benefits of the different formats were emphasised.
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Affiliation(s)
- Chika K. Egenasi
- Department of Family Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| | - Anandan A. Moodley
- Department of Neurology, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Wilhelm J. Steinberg
- Department of Family Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| | - Anthonio O. Adefuye
- Division of Health Sciences Education, Faculty of Health Science, University of the Free State, Bloemfontein, South Africa
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Patel AD, Becker DA. Introduction to use of an acute seizure action plan for seizure clusters and guidance for implementation. Epilepsia 2022; 63 Suppl 1:S25-S33. [PMID: 35999175 DOI: 10.1111/epi.17344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/08/2022] [Accepted: 06/08/2022] [Indexed: 11/29/2022]
Abstract
It is important for patients with epilepsy and their caregivers, including care partners, to understand the patient's seizure clusters and what to do when they occur. In many instances, seizure clusters are unique to each patient. The knowledge gained from understanding a patient's seizure cluster or seizure pattern provides a foundation for taking prompt action to prevent worsening to prolonged seizures, status epilepticus, and potentially death. Seizure action plans (SAPs), which are similar to the disease-related treatment action plans for other conditions, can be developed by a health care provider (HCP) in conjunction with the patient with epilepsy and/or caregivers, and SAPs are specifically customized for the individual patient and his or her seizure management. However, the current literature lacks unified guidance on how to design SAPs that will help prepare patients and caregivers for rapidly determining and initiating appropriate treatment of acute seizure emergencies in the community and at home. Here, we examine the current usage and value of SAPs for pediatric and adult patients with epilepsy, and we introduce the concept of the acute SAP (ASAP) for use specifically during seizure emergencies, such as seizure clusters. This type of standardized, simplified, and customized plan can rapidly and concisely provide patients and caregivers with a practical protocol to treat a seizure cluster consistently, appropriately, and in a timely manner. Details on potential content and formats of ASAPs are provided. Following this is a discussion of barriers to ASAP use that may affect HCPs or patients and caregivers, including lack of standardization, relevance, and personalization and pitfalls associated with technology. This leads into a discussion of guidance for developing, implementing, and updating ASAPs that suggests ways to address the barriers and ensure that the ASAP is best suited to the patient's needs.
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Affiliation(s)
- Anup D Patel
- Division of Neurology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Danielle A Becker
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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22
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Blond BN, Hirsch LJ. Updated review of rescue treatments for seizure clusters and prolonged seizures. Expert Rev Neurother 2022; 22:567-577. [PMID: 35862983 DOI: 10.1080/14737175.2022.2105207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Although the treatment of epilepsy primarily focuses on prevention, recurrent seizures are unfortunately an ongoing reality, particularly in people with epilepsy who live with chronic refractory seizures. Rescue medications are agents which can be administered in urgent/emergent seizure episodes such as seizure clusters or prolonged seizures with the goal of terminating seizure activity, preventing morbidity, and decreasing the risk of further seizures. AREAS COVERED This review first discusses clinical opportunities for rescue medications, with particular attention focused on seizure clusters and prolonged seizures, including their epidemiology, risk factors, and associated morbidity. Current rescue medications, their indications, efficacy, and adverse effects are discussed. We then discuss rescue medications and formulations which are currently under development, concentrating on practical aspects relevant for clinical care. EXPERT OPINION Rescue medications should be considered for all people with epilepsy with ongoing seizures. Recent rescue medications including intranasal formulations provide considerable advantages. New rescue medications are being developed which may expand opportunities for effective treatment. In the future, combining rescue medications with seizure detection and seizure prediction technologies should further expand opportunities for use and should reduce the morbidity of seizures and provide increased comfort, control, and quality of life for people living with epilepsy.
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Affiliation(s)
- Benjamin N Blond
- Department of Neurology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY
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Lu YT, Lin CH, Ho CJ, Hsu CW, Tsai MH. Evaluation of Cardiovascular Concerns of Intravenous Lacosamide Therapy in Epilepsy Patients. Front Neurol 2022; 13:891368. [PMID: 35860491 PMCID: PMC9289181 DOI: 10.3389/fneur.2022.891368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 06/15/2022] [Indexed: 12/04/2022] Open
Abstract
Objective Voltage-gated sodium channels (VGSCs) play an important role in neuronal excitability and epilepsies. In addition to the brain, VGSCs are also abundant enriched in cardiac tissues and are responsible for normal cardiac rhythm. Theoretically, sodium channel blocking antiseizure medications (SCB-ASMs) may have unwanted cardiac side effects. Lacosamide (LCM) is increasingly used in patients with status epilepticus (SE) due to the availability of intravenous formula. The concerns about the proarrhythmic effect are even higher due to the need for rapid administration of LCM. There were limited data on the cardiac safety of intravenous LCM. Hereby, we performed a study to observe the effect of intravenous loading of LCM in patients with seizures in our Neurological Intensive Care Unit (NICU). Methods We retrospectively reviewed the patients using parenteral LCM for seizures in NICU. A routine infusion time of 30 min was performed. The electrocardiogram (ECG) and blood pressure were recorded before and after LCM injection. Results We retrospectively reviewed the clinical data of 38 patients using LCM for treating seizures. Two patients had cardiac side effects after LCM loading, one (3.0%) with new-onset first-degree AV block and the other (3.0%) with atrial premature complex. For the quantitative changes of ECG parameter analysis, there was no change in QRS complex, corrected QT intervals, and heart rate except that the PR interval was mildly increased. A mild decrease in the diastolic blood pressure and mean arterial pressure were also observed. None of the above-mentioned parameter alterations required clinical intervention. Conclusion We evaluated the cardiac safety concern in real-world epilepsy patients requiring intravenous LCM. Near half of this cohort responded to LCM therapy and there was no life-threatening cardiac adverse effect. Intravenous LCM does have some effects on the ECG parameters and blood pressure but without clinical relevance. Despite the theoretical concern of cardiac adverse effects of LCM, the benefit of seizure control outweighed the risk in patients with status epilepticus or seizure clusters, such as hyperthermia, pulmonary edema, cardiac arrhythmias, or cardiovascular collapse.
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Affiliation(s)
- Yan-Ting Lu
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung, Taiwan
| | - Chih-Hsiang Lin
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung, Taiwan
| | - Chen-Jui Ho
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung, Taiwan
| | - Che-Wei Hsu
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung, Taiwan
| | - Meng-Han Tsai
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Genomics and Proteomics Core Laboratory, Department of Medical Research, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- *Correspondence: Meng-Han Tsai
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24
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Becker DA. Empowering With Rescue Therapy: A Rescue for More than Just Seizures. Epilepsy Curr 2022; 22:164-165. [PMID: 36474825 PMCID: PMC9684586 DOI: 10.1177/15357597221079448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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25
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Cascino GD, Tarquinio D, Wheless JW, Hogan RE, Sperling MR, Desai J, Vazquez B, Samara E, Misra SN, Carrazana E, Rabinowicz AL. Lack of Clinically Relevant Differences in Safety and Pharmacokinetics After Second-Dose Administration of Intranasal Diazepam Within 4 Hours for Acute Treatment of Seizure Clusters: A Population Analysis. Epilepsia 2022; 63:1714-1723. [PMID: 35377464 PMCID: PMC9543781 DOI: 10.1111/epi.17249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/01/2022] [Accepted: 04/01/2022] [Indexed: 11/30/2022]
Abstract
Objective Current diazepam nasal spray labeling requires waiting 4 h before administering a second dose. The objective of the current analyses was to examine safety and pharmacokinetic profiles of second doses of diazepam nasal spray given 0−4 h after the first dose. Methods Two datasets were analyzed. The first, a long‐term, repeat‐dose safety study of diazepam nasal spray, compared rates of treatment‐emergent adverse events (TEAEs), serious TEAEs, and treatment‐related TEAEs for patients receiving ≥1 second dose ≤4 h versus all second doses >4 h after the first. The second was a population pharmacokinetic analysis using data from three phase 1 studies to model drug exposure when a second dose of diazepam nasal spray was administered across multiple time points (1 min−4 h) following the first dose. Results In the repeat‐dose safety study, a second dose of diazepam nasal spray was administered ≤24 h after the first to treat 485 seizure clusters in 79 patients. Rates of TEAEs were similar between patients receiving ≥1 second dose in ≤4 h (89.5%, n = 38) compared with >4–24 h only (80.5%, n = 41). The most common treatment‐related TEAEs were associated with nasal discomfort, which was mild or moderate and transient. There were no reports of respiratory or cardiac depression. The pharmacokinetic simulations of second doses predicted comparable elevations of plasma diazepam concentrations with administrations across a range of intervals after the first dose (1 min−4 h). Significance These data indicate that the safety and pharmacokinetic profiles of a second dose of diazepam nasal spray administered within 4 h of the first dose are consistent with those associated with current labeling. This is potentially important for patients with seizure clusters who have a recurrent seizure within 4 h of first treatment and might benefit from immediate retreatment to reduce the risk of progression to status epilepticus.
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Affiliation(s)
| | | | - James W Wheless
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | | | | | - Jay Desai
- Children's Hospital of Los Angeles, CA, USA
| | - Blanca Vazquez
- New York University, Comprehensive Epilepsy Center, New York, NY, USA
| | - Emil Samara
- PharmaPolaris International, Inc, Washington, DC, USA
| | | | - Enrique Carrazana
- Neurelis, Inc., San Diego, CA, USA.,John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
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Abstract
PURPOSE OF REVIEW The purpose of this review is to provide a succinct evaluation of the current rescue medications and action plans available to our patients with seizure clusters in the outpatient setting. RECENT FINDINGS The main themes of the recent findings are that rescue medications and seizure action plans (SAPs) are underutilized, particularly in the adult population. The safety and efficacy of intranasal midazolam and intranasal diazepam is comparable with rectal diazepam for the treatment of seizure clusters. Additionally, this intranasal formulation has the benefit of a more socially acceptable route of administration and ease of use. SUMMARY The implication of these findings is a greater variety and awareness in the rescue medications available to our patients suffering from seizure clusters.
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Affiliation(s)
- Sonali Sharma
- University of Miami, Miller School of Medicine, Miami, Florida, USA
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Alcoreza O, Jagarlamudi S, Savoia A, Campbell SL, Sontheimer H. Sulfasalazine decreases astrogliosis-mediated seizure burden. Epilepsia 2022; 63:844-854. [PMID: 35132640 PMCID: PMC9007880 DOI: 10.1111/epi.17178] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 01/18/2022] [Accepted: 01/18/2022] [Indexed: 02/06/2023]
Abstract
Objective Previously, we reported that inhibition of the astrocytic cystine/glutamate antiporter system xc‐ (SXC), using sulfasalazine (SAS), decreased evoked excitatory signaling in three distinct hyperexcitability models ex vivo. The current study expands on this work by evaluating the in vivo efficacy of SAS in decreasing astrogliosis‐mediated seizure burden seen in the beta‐1 integrin knockout (B1KO) model. Methods Video‐EEG (electroencephalography) monitoring (24/7) was obtained using Biopac EEG acquisition hardware and software. EEG spectral analysis was performed using MATLAB. SAS was used at an equivalence of doses taken by Crohn’s disease patients. Whole‐cell patch‐clamp recordings were made from cortical layer 2/3 pyramidal neurons. Results We report that 100% of B1KO mice that underwent 24/7 video‐EEG monitoring developed spontaneous recurrent seizures and that intraperitoneal administration of SAS significantly reduced seizure frequency in B1KOs compared to B1KOs receiving sham saline. Spectral analysis found an acute reduction in EEG power following SAS treatment in B1KOs; however, this effect was not observed in nonepileptic control mice receiving SAS. Finally, whole‐cell recordings from SXC knockout mice had hyperpolarized neurons and SXC‐B1 double knockouts fired significantly less action potentials in response to current injection compared to B1KOs with SXC. Significance To devise effective strategies in finding relief for one‐in‐three patients with epilepsy who experience drug‐resistant epilepsy we must continue to explore the mechanisms regulating glutamate homeostasis. This study explored the efficacy of targeting an astrocytic glutamate antiporter, SXC, as a novel antiepileptic drug (AED) target and further characterized a unique mouse model in which chronic astrogliosis is sufficient to induce spontaneous seizures and epilepsy. These findings may serve as a foundation to further assess the potential for SAS or inform the development of more potent and specific compounds that target SXC as a novel treatment for epilepsy.
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Affiliation(s)
- Oscar Alcoreza
- Fralin Biomedical Research Institute, Center for Glial Biology in Health, Disease and Cancer, Virginia Tech, Roanoke, Virginia, USA.,Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Sai Jagarlamudi
- School of Neuroscience, Virginia Tech, Blacksburg, Virginia, USA
| | - Andrew Savoia
- School of Neuroscience, Virginia Tech, Blacksburg, Virginia, USA
| | - Susan L Campbell
- Animal and Poultry Sciences, Virginia Tech, Blacksburg, Virginia, USA
| | - Harald Sontheimer
- Fralin Biomedical Research Institute, Center for Glial Biology in Health, Disease and Cancer, Virginia Tech, Roanoke, Virginia, USA
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Zhong R, Chen Q, Zhang X, Lin W. The Occurrence of Seizure Clusters in Patients With Epilepsy Is Partly Determined by Epilepsy Severity: A Single-Center Retrospective Observational Study. Front Neurol 2021; 12:794086. [PMID: 34956069 PMCID: PMC8695898 DOI: 10.3389/fneur.2021.794086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 11/10/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: This retrospective observational study aimed to investigate the self-reported prevalence of seizure clusters (SCs) in patients with epilepsy (PWE) and its relationship with clinical characteristics. Methods: We retrospectively analyzed data from consecutive PWE from our hospital in northeastern China. Data were collected from the databank of a tertiary epilepsy center. Logistic regression models were employed to investigate the relationships between the individual patient demographic/clinical variables and the occurrence of SC. Results: In total, 606 consecutive PWE were included in the final analysis, and 268 (44.2%) patients experienced at least one seizure cluster. In multivariate logistic regression models, age (OR: 1.014; 95% CI: 1.002–1.027; p = 0.02), seizure frequency (OR: 2.08; 95% CI: 1.555–2.783; p < 0.001), multiple seizure types (OR: 5.111; 95% CI: 1.737–15.043; p = 0.003), number of current anti-seizure medications (ASM) (OR: 1.533; 95% CI: 1.15–2.042; p = 0.004), drug-resistant epilepsy (OR: 1.987; 95% CI: 1.159–3.407; p = 0.013), and a history of status epilepticus (OR: 1.903; 95% CI: 1.24–2.922; p = 0.003) were independent variables associated with a history of SC in PWE. Conclusion: Seizure clusters (SCs) are common occurrences at our study center. The occurrence of SC in individuals with epilepsy, to some extent, is determined by the epilepsy severity.
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Affiliation(s)
- Rui Zhong
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Qingling Chen
- Department of Hepatology, Second People's Clinical College of Tianjin Medical University, Tianjin, China
| | - Xinyue Zhang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Weihong Lin
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
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Liu H, Zhang L. Clustering of Spontaneous Recurrent Seizures in a Mouse Model of Extended Hippocampal Kindling. Front Neurol 2021; 12:738986. [PMID: 34899563 PMCID: PMC8654732 DOI: 10.3389/fneur.2021.738986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 11/05/2021] [Indexed: 02/03/2023] Open
Abstract
Acute repetitive seizures or seizure clusters are common in epileptic patients. Seizure clusters are associated with a high risk of developing status epilepticus and increased morbidity and mortality. Seizure clusters are also recognizable in spontaneous recurrent seizures (SRS) that occur in animal models of epilepsy. The electrical kindling of a limbic structure is a commonly used model of temporal lobe epilepsy. Although classic kindling over the course of a few weeks does not generally induce SRS, extended kindling over the course of a few months can induce SRS in several animal species. SRS in kindled cats often occur in clusters, but the existence of seizure clusters in rodent models of extended kindling remains to be demonstrated. We explored the existence of seizure clusters in mice following extended hippocampal kindling. Adult male mice (C57BL/6) experienced twice daily hippocampal stimulations and underwent continuous 24-hour electroencephalogram (EEG)-video monitoring after ≥80 stimulations. SRS events were recognized by EEG discharges and associated motor seizures. Seizure clusters, defined as ≥4 seizures per cluster and intra-cluster inter-seizure intervals ≤ 120 min, were observed in 19 of the 20 kindled mice. Individual mice showed variable seizure clusters in terms of cluster incidence and circadian-like expression patterns. For clusters consisting of 4-7 seizures and intra-seizure intervals ≤ 20 min, no consistent changes in inter-seizure intervals, EEG discharge duration, or motor seizure severity scores were observed approaching cluster termination. These results suggested that seizure clustering represents a prominent feature of SRS in hippocampal kindled mice. We speculate that, despite experimental limitations and confounding factors, systemic homeostatic mechanisms that have yet to be explored may play an important role in governing the occurrence and termination of seizure clusters.
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Affiliation(s)
- Haiyu Liu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China.,Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - Liang Zhang
- Krembil Research Institute, University Health Network, Toronto, ON, Canada.,Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
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30
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The rescue therapy in epilepsy project Part 2: Insights from people with epilepsy and families on expert-derived preferred practices. Epilepsy Behav 2021; 125:108444. [PMID: 34839243 DOI: 10.1016/j.yebeh.2021.108444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 11/10/2021] [Accepted: 11/10/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND The number and type of therapies available to treat seizure clusters (SCs) or periods of increased seizure activity have risen in recent years. Gaps still exist on defining SCs, when to use them, and educating patients and families. The Epilepsy Foundation developed and published expert-derived consensus on preferred practices for rescue therapies (RTs), 79% of which were agreed upon by a larger group of healthcare professionals (HCPs). This paper describes insights from people with epilepsy (PWE) and families/caregivers (FCGs) on these practices to assess similarities and trends between PWE, FCGs, an expert panel, and HCPs. METHODS Online survey including expert-derived preferred practices for RT was completed by a convenience sample of 176 PWE/FCGs. Respondents rated agreement with each preferred practice using a 0-8 point Likert scale. Results were examined by relationship to epilepsy, prior use of RTs, and comparison to the expert panel and larger group of HCPs. RESULTS 41.5% of respondents were PWE and 54.6% were FCGs; 70% represented PWE age 18 and over or those who cared for adults with epilepsy. Levels of agreement were similar to those of HCPs - consensus was obtained on 79% of preferred practices. Differences were noted on which items achieved consensus and strength of consensus for some items. Differences between PWE and FCG, and between those who had and had not previously used a RT were found. A proposed definition of SCs did not reach consensus, but there was strong consensus for individualized seizure action plans and more RT education.
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Penovich P, Glauser T, Becker D, Patel AD, Sirven J, Long L, Stern J, Dixon-Salazar T, Carrazana E, Rabinowicz AL. Recommendations for development of acute seizure action plans (ASAPs) from an expert panel. Epilepsy Behav 2021; 123:108264. [PMID: 34482230 DOI: 10.1016/j.yebeh.2021.108264] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW Disease-related treatment action plans for acute exacerbations providing information that may be helpful for self-management for patients and caregivers are commonly used for chronic conditions such as asthma and diabetes. However, among patients with epilepsy, a review of the literature suggested that the majority did not have an action plan in place for acute seizure treatment. RECENT FINDINGS Currently, there is a lack of unified guidance on seizure action plans (SAPs) in the literature. In the authors' opinion, available formats have limitations for practical use and may not be easily customizable to individual patients, and they are not often designed to provide simple-to-follow steps for rapid immediate steps to determine and initiate appropriate treatment of seizure emergencies. Our group reviewed current examples of SAPs and provided guidance on the development of acute seizure action plans (ASAPs) designed to facilitate rapid, appropriate acute care in the community and to be as useful as possible for a wide range of care partners, including those with limited experience. SUMMARY This paper provides agreed upon expert opinion recommendations and considerations for goals, development process, types of content, and format for an ASAP.
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Affiliation(s)
| | - Tracy Glauser
- Comprehensive Epilepsy Center, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Danielle Becker
- Case Western Reserve University School of Medicine and MetroHealth System, Cleveland, OH, USA
| | - Anup D Patel
- Neurology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Joseph Sirven
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - Lucretia Long
- Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - John Stern
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
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Malgireddy K, Gupta N, Baang HY, Samson KK, Madhavan D, Puccioni M, Taraschenko O. Risk of seizure clusters and status epilepticus following rapid and ultra-rapid medication discontinuation during intracranial EEG monitoring. Epilepsy Res 2021; 177:106756. [PMID: 34543831 DOI: 10.1016/j.eplepsyres.2021.106756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 08/12/2021] [Accepted: 09/07/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Anti-seizure medications (ASMs) are discontinued in the course of intracranial EEG (iEEG) monitoring for presurgical evaluation. The ASM withdrawal facilitates an emergence of seizures but may also precipitate seizure clusters (SC) and status epilepticus (SE). The aim of this study was to compare the rates of SC and SE during the ultra-rapid withdrawal (URW) and rapid withdrawal (RW) of ASMs during iEEG. METHODS We performed a retrospective observational study of all consecutive patients with drug resistant epilepsy who completed iEEG at our comprehensive epilepsy center from 2012-2018. SC was defined as three or more seizures in 24 h with a return to baseline between the events. SE was defined as ≥ 5 min of clinical seizure or ≥ 10 min of ictal electrographic activity or series of seizures with no return to the neurological baseline between the events. RESULTS Of 107 patients who completed iEEG with intracranial grid or strip electrodes, 46 (43%) were male. Median age at the time of iEEG was 35.4 years (interquartile range [IQR], 26.4 - 44.9). Ninety patients (84.1%) had all AEDs held on admission, while 16 patients (15%) underwent a rapid taper. The median time to first seizure was 15.1 (8.2 - 22.6) h. Sixty-two patients (57.9%) developed SC, while 10 (9.4%) developed SE. Twenty-six patients (36.1%) with these complications required intravenous lorazepam or other rescue ASMs, while the remaining patients had spontaneous resolution of seizures; intubations were not required. While there were differences in the proportions in patients who experienced SC, SE, or neither in the URW and RW groups, these differences were not significant at the 0.05 alpha level. SIGNIFICANCE Ultra-rapid and rapid ASM withdrawal are accompanied by SC and SE the majority of which terminate spontaneously. These data support the use of either approach of the medication taper for seizure provocation in iEEG.
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Affiliation(s)
- Kalyan Malgireddy
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, 68198-8435, USA
| | - Navnika Gupta
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, 68198-8435, USA
| | - Hae Young Baang
- Department of Critical Care Medicine, Yale University School of Medicine, New Haven, Connecticut, 06516, USA
| | - Kaeli K Samson
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, Nebraska, 68198-4375, USA
| | - Deepak Madhavan
- Boys Town Research Hospital, Boys Town, Nebraska, 68010, USA
| | | | - Olga Taraschenko
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, 68198-8435, USA.
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Chung S, Szaflarski JP, Choi EJ, Wilson JC, Kharawala S, Kaur G, Hirsch LJ. A systematic review of seizure clusters: Prevalence, risk factors, burden of disease and treatment patterns. Epilepsy Res 2021; 177:106748. [PMID: 34521043 DOI: 10.1016/j.eplepsyres.2021.106748] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 08/05/2021] [Accepted: 08/24/2021] [Indexed: 11/17/2022]
Abstract
Seizure clusters (SCs) are episodes of consecutive seizures that occur within a short period. The treatment patterns of rescue medications (RMs), as well as the burden of SCs, have not been assessed. A systematic literature search on Embase.com (in PubMed and Embase), supplemented with keyword-based and bibliographic searches, identified 44 articles for disease burden, three treatment guidelines, and three articles for treatment patterns. Common SC definitions were ≥3 seizures/24 h, ≥2/24 h and ≥2/6 h. The rate of SCs in prospective studies ranged from 21.7 %-42.5 %. The frequency of status epilepticus (SE) was higher in SC patients. SCs were associated with higher seizure frequency, higher risk of treatment resistance, and lower likelihood of seizure remission. Quality of life (QoL) was lower in children with SCs than in those with isolated seizures. Seizure-related hospitalization was more common in SC than non-SC patients. SCs adversely affected the productivity of patients and their caregivers. In outpatients with SCs, RMs were prescribed to 24.6 %-89.6 % and utilized by 15.6 %-44.5 %, with rates being higher in children. Key reasons for RM under-utilization were lack of seizure action plans, poor physician-patient communication, and concerns with administration route. In conclusion, SCs are associated with a higher risk of SE, treatment resistance, and low rate of seizure remission. They adversely affect patient and caregiver QoL and work productivity. However, RMs are under-prescribed, and there is an urgent need to improve recognition of SCs, improve use of seizure action plans, and remove barriers to RM use.
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Affiliation(s)
- Steve Chung
- Banner University Medical Center, University of Arizona, Phoenix, AZ, USA.
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34
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Abstract
Acute repetitive seizures, also called seizure clusters, are common phenomena in patients with epilepsy. They are a burden on patients and their caregivers and may be very disruptive to the patients' lives. They may progress to prolonged seizures or status epilepticus if they are not aborted as soon as possible. However, their definition, recognition, and classification still suffer from a lack of consensus among healthcare professionals in the field. This review aims to shed light on various aspects of seizure clusters with particular attention to their treatments.
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Affiliation(s)
- Boulenouar Mesraoua
- Hamad Medical Corporation, Doha, Qatar.,Weill Cornell Medical College, Doha, Qatar
| | - Bassel Abou-Khalil
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Gayane Melikyan
- Hamad Medical Corporation, Doha, Qatar.,Weill Cornell Medical College, Doha, Qatar
| | - Hassan Al Hail
- Hamad Medical Corporation, Doha, Qatar.,Weill Cornell Medical College, Doha, Qatar
| | - 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
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Buchhalter J, Shafer PO, Buelow JM, French JA, Gilchrist B, Hirsch LJ, Nasuta M, Santilli N. Preferred practices for rescue treatment of seizure clusters: A consensus-driven, multi-stakeholder approach. Epilepsy Behav 2021; 117:107836. [PMID: 33640567 DOI: 10.1016/j.yebeh.2021.107836] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 01/30/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Some of the most difficult issues in the care of people living with epilepsy (PWE) regard the definition, treatment, and communication of unexpected increase(s) in seizure frequency over a relatively short duration of time. In order to address this issue, the Epilepsy Foundation established the Rescue Therapy Project in Epilepsy to understand the gaps, needs, and barriers facing people with epilepsy who use or may benefit from rescue therapies (RTs) for "seizure clusters". The intent was to provide consensus-derived recommendations from a broad stakeholder group including PWE, their caregivers, epilepsy specialist physicians, nurses, pharmacists, and representatives of epilepsy & neurology advocacy and professional organizations. METHODS During Phase 1, a group of epilepsy experts and stakeholders (N = 54) were divided into 3 workgroups that met by conference calls and in-person. Content of workgroups was developed into preferred practices related to RTs. In Phase 2, these recommendations were evaluated by a larger more diverse group of healthcare professionals, PWE, and caregivers. Agreement with recommended preferred practices at 80% or greater was set as the level to achieve consensus. RESULTS The preferred practices were centered around four core themes identified by the experts and key stakeholders: the importance of a common language; when RTs should be prescribed; assessing the need for RTs; and education/communication about RTs. Consensus from experts and key stakeholders was reached for 27 recommended preferred practices using the Delphi method. "Rescue therapy" or "rescue medicine" was the preferred term to describe what to name a treatment intervention in this context, and seizure action plans was the preferred term to communicate how to respond to a seizure or SCs and the use of RTs. In Phase 2, 23 of the recommendations reached final consensus, including the need for a common language, and the need to consider RTs and seizure action plans in all PWE in an individualized manner, several circumstances in which RTs should be prescribed, and the importance of education regarding RTs and SAPs.
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Affiliation(s)
| | - Patricia O Shafer
- Osborne Health Consulting LLC, Boston, MA, USA; Epilepsy Foundation, Landover, MD, USA
| | | | - Jaqueline A French
- Department of Neurology, NYU Grossman School of Medicine, New York City, NY, USA; Epilepsy Foundation, Landover, MD, USA
| | | | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Dept. of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Mary Nasuta
- Harford County Public Schools, Bel Air, MD, USA
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Wheless JW. A critical evaluation of midazolam nasal spray for the treatment of patients with seizure clusters. Expert Rev Neurother 2021; 21:1195-1205. [PMID: 33593228 DOI: 10.1080/14737175.2021.1890033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Patients with epilepsy may experience seizure clusters (SCs), which are considered a medical emergency requiring immediate treatment. Besides seizures and seizure-related injuries, patients with SCs experience impaired quality of life and have a greater need for healthcare resources. Midazolam nasal spray (MDZ-NS) was approved by the United States Food and Drug Administration (FDA) for the treatment of SCs in 2019, and was the first FDA-approved nasally administered formulation for treating SCs.Areas covered: This article provides a critical evaluation of MDZ-NS for the treatment of patients with SCs. It covers the chemistry, pharmacodynamic and pharmacokinetic properties of MDZ-NS, and safety, tolerability, and efficacy data from phase I and phase III trials. SC treatment guidelines in different countries and for alternative therapies are also discussed.Expert opinion: Midazolam is a well-established drug that is familiar to physicians. The newer MDZ-NS formulation offers the benefits of intranasal administration, which allows for outpatient treatment by caregivers and other non-healthcare professionals when an SC occurs, and may be particularly meaningful to patients with limited treatment options because other routes of administration are unsuitable. MDZ-NS is effective and patients are known to return to baseline alertness and psychomotor function within 240 minutes after administration.
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Affiliation(s)
- James W Wheless
- Le Bonheur Comprehensive Epilepsy Program & Neuroscience Institute, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Bauman K, Devinsky O. Seizure Clusters: Morbidity and Mortality. Front Neurol 2021; 12:636045. [PMID: 33664705 PMCID: PMC7920959 DOI: 10.3389/fneur.2021.636045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 01/25/2021] [Indexed: 11/18/2022] Open
Abstract
Seizure clusters, an intermediate between single seizure and status epilepticus, are associated with morbidity, impaired quality of life, and premature mortality. The relationship between seizure clusters and sudden unexplained death in epilepsy (SUDEP) is poorly understood. Here, we define seizure clusters; review comorbid psychiatric disorders and memory deficits associated with seizure clusters; and review cases of witnessed SUDEP for which seizure frequency prior to death is available. Patients with a history of seizure clusters have a 2.5 fold increased risk for SUDEP, and one third of patients with monitored in hospital SUDEP experienced a cluster of generalized tonic clonic seizures prior to death. Understanding the effects of seizure frequency and duration on SUDEP risk could yield new insights in SUDEP pathophysiology and new targets for intervention.
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Affiliation(s)
- Kristie Bauman
- Department of Neurology, NYU Grossman School of Medicine and NYU Langone Comprehensive Epilepsy Center, New York, NY, United States
| | - Orrin Devinsky
- Department of Neurology, NYU Grossman School of Medicine and NYU Langone Comprehensive Epilepsy Center, New York, NY, United States
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Identification of seizure clusters using free text notes in an electronic seizure diary. Epilepsy Behav 2020; 113:107498. [PMID: 33096508 DOI: 10.1016/j.yebeh.2020.107498] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/09/2020] [Accepted: 09/12/2020] [Indexed: 11/21/2022]
Abstract
SIGNIFICANCE Online seizure diaries offer a wealth of information regarding real world experience of patients living with epilepsy. Free text notes (FTN) written by patients reflect concerns and priorities of patients and provide supplemental information to structured diary data. OBJECTIVE This project evaluated feasibility using an automated lexical analysis to identify FTN relevant to seizure clusters (SCs). METHODS Data were extracted from EpiDiary™, a free electronic epilepsy diary with 42,799 unique users, generating 1,096,168 entries and 247,232 FTN. Both structured data as well as FTN were analyzed for presence of SC. A pilot study was conducted to validate an automated lexical analysis algorithm to identify SC in FTN in a sample of 98 diaries. The lexical analysis was then applied to the entire dataset. Outcomes included cluster prevalence and frequency, as well as the types of triggers commonly reported. RESULTS At least one FTN was found among 13,987 (32.68%) individual diaries. An automated lexical analysis algorithm identified 5797 of FTN as SC. There were 2423 unique patients with SC that were not identified by structured data alone and were identified using lexical analysis of FTN only. Seizure clusters were identified in n = 10,331 (24.1%) of diary users through both structured data and FTN. The median number of SCs days per year was 13.7, (interquartile rank (IQR): 3.2-54.7). The median number of seizures in a cluster day was 3 (IQR 2-4). The most common missed medication linked to patients with SC was levetiracetam (n = 576, 29%) followed by lamotrigine (n = 495, 24%), topiramate (n = 208, 10.5%), carbamazepine (n = 190, 9.6%), and lacosamide (n = 170, 8.6%). These percentages generally reflected prevalence of medication use in this population. The use of rescue medications was documented in 3306 of structured entries and 4305 in FTN. CONCLUSION This exploratory study demonstrates a novel approach applying lexical analysis to previously untapped FTN in a large electronic seizure diary database. Free text notes captured information about SC not available from the structured diary data. Diary FTN contain information of high importance to people with epilepsy, written in their own words.
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Gidal B, Klein P, Hirsch LJ. Seizure clusters, rescue treatments, seizure action plans: Unmet needs and emerging formulations. Epilepsy Behav 2020; 112:107391. [PMID: 32898744 DOI: 10.1016/j.yebeh.2020.107391] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/29/2020] [Accepted: 07/30/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW The aim of the study was to provide an overview of the prevalence, risk factors, burden, and current and emerging pharmacologic treatments for seizure clusters in patients with epilepsy. RECENT FINDINGS Close to half of patients with active epilepsy experience seizure clusters, and the clinical, social, and financial burdens of seizure clusters are high. However, there is no widely accepted definition of seizure clusters; their prevalence is underappreciated, contingencies for addressing them (seizure action plans) are often lacking, and their effects are not well-studied. These issues have resulted in an insufficient number of investigations and approved medications for this condition. Novel formulations are in late-stage development to meet this unmet need.
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Affiliation(s)
- Barry Gidal
- University of Wisconsin-Madison, School of Pharmacy, Madison, WI, USA.
| | - Pavel Klein
- Mid-Atlantic Epilepsy and Sleep Center, Bethesda, MD, USA
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Seinfeld S, Gelfand MA, Heller AH, Buan C, Slatko G. Safety and tolerability associated with chronic intermittent use of diazepam buccal film in adult, adolescent, and pediatric patients with epilepsy. Epilepsia 2020; 61:2426-2434. [PMID: 32944970 PMCID: PMC7756501 DOI: 10.1111/epi.16696] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/25/2020] [Accepted: 08/25/2020] [Indexed: 02/06/2023]
Abstract
Objective Diazepam buccal film (DBF) is in development for treatment of patients experiencing bouts of increased seizure activity. We assessed safety, tolerability, and usability of self‐ or caregiver‐administered DBF in the outpatient setting. Methods Patients aged 2‐65 years needing treatment with a rescue benzodiazepine at least once monthly were eligible for the study. DBF (5‐17.5 mg) was dispensed based on age and body weight. Patients/caregivers administered DBF for up to five seizure episodes per month. Adverse events (AEs) and usability assessments were recorded after the first dose, then every 3 months. Results Onehundred eighteen patients who used ≥1 DBF dose (adults, n = 82; adolescents, n = 19; children, n = 17) were enrolled. Eleven treatment‐related AEs (10 being mild or moderate in severity) occurred in nine (7.6%) patients over a mean of 243 days of follow‐up. No patient discontinued participation because of AEs. Mild local buccal discomfort, buccal swelling, and cheek skin sensitivity were reported by one patient each. Twenty‐two serious AEs were reported; one was treatment‐related. The three deaths reported, all unrelated to DBF, resulted from seizures or seizure with brain malignancy. Self‐administration by adults was attempted on 23.6% (188/795) of use occasions. Administration of DBF occurred under ictal or peri‐ictal conditions on 49.5% (538/1087) of use occasions, and DBF was successfully administered on a first or second attempt on 96.6% (1050/1087) of use occasions. Overall, patients received their dose of DBF on 99.2% (1078/1087) of use occasions. A second DBF dose was required within 24 hours after the first dose on 8.5% (92/1087) of use occasions. Significance In this observational study of chronic intermittent use, DBF was easy to administer, safe, and well tolerated in adult, adolescent, and pediatric patients with epilepsy experiencing seizure emergencies. DBF can be readily self‐administered by adults with epilepsy, as well as successfully administered by a caregiver in seizure emergencies.
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Affiliation(s)
| | | | | | - Carla Buan
- Aquestive Therapeutics, Inc., Warren, NJ, USA
| | - Gary Slatko
- Aquestive Therapeutics, Inc., Warren, NJ, USA
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Szaflarski JP, Sadek A, Greve B, Williams P, Varner JA, Moseley BD. Randomized open-label trial of intravenous brivaracetam versus lorazepam for acute treatment of increased seizure activity. Epilepsy Behav 2020; 109:107127. [PMID: 32417382 DOI: 10.1016/j.yebeh.2020.107127] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 04/20/2020] [Accepted: 04/20/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The objective of the present trial was to assess efficacy and safety of intravenous (IV) brivaracetam (BRV) vs. lorazepam (LZP) in patients with epilepsy undergoing evaluation in an epilepsy monitoring unit (EMU) who experienced seizures requiring acute treatment. METHODS This was a phase 2, open-label, randomized, active-control, proof-of-concept trial (EP0087; NCT03021018). Patients (18-70 years) admitted to EMU were randomized 1:1:1 to single-dose bolus IV LZP (dose per investigator's practice), IV BRV 100 mg, or IV BRV 200 mg. Trial medication had to be administered within 30 min of qualifying seizure. Primary efficacy outcome was time to next seizure (clinical observation with electroencephalogram [EEG] confirmation) or to rescue medication use within 12 h of trial medication administration. Secondary outcomes included seizure freedom and rescue medication use within 12 h of trial medication administration. Safety and tolerability outcomes included treatment-emergent adverse events (TEAEs). RESULTS Overall, 46 patients were randomized, and 45 received trial medication for a qualifying seizure. Patients in the LZP arm had doses from 1 to 4 mg (median: 1 mg). Eleven of 45 patients had a seizure within 12 h of trial medication administration (LZP 5/15 [median time to next seizure: 5.55 h], BRV 100 mg 3/15 [5.97 h], BRV 200 mg 3/15 [3.60 h]). No patients received additional rescue medication to control their qualifying seizure. Most patients were seizure-free over 12 h (LZP 9/15 [60.0%], BRV 100 mg 12/15 [80.0%], BRV 200 mg 12/15 [80.0%]). Rescue medication use within 12 h was numerically higher for LZP (6/15 [40.0%]) vs. BRV 100 mg (1/15 [6.7%]) and vs. BRV 200 mg (2/15 [13.3%]). Treatment-emergent adverse events were reported by 5/16 (31.3%), 6/15 (40.0%), and 3/15 (20.0%) of LZP, BRV 100 mg, and BRV 200 mg patients; one LZP patient had a serious TEAE (seizure cluster). Most common TEAEs (≥10% of patients) were sedation and somnolence with LZP, and dizziness, headache, and nausea with BRV. SIGNIFICANCE Intravenous LZP, IV BRV 100 mg, and IV BRV 200 mg showed similar efficacy in controlling acute seizure activity in the EMU. Treatment-emergent adverse events were as expected for each medication. Although this trial should be interpreted with caution because of small patient numbers, it suggests a possible role of BRV in the acute treatment of increased seizure activity.
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Affiliation(s)
- Jerzy P Szaflarski
- University of Alabama at Birmingham, Department of Neurology and the UAB Epilepsy Center, 1719 6th Avenue South, CIRC 312, Birmingham, AL 35294, USA.
| | - Ahmed Sadek
- Neurological Services of Orlando, 3849 Oakwater Cir, Orlando, FL 32806, USA.
| | - Bernhard Greve
- UCB Pharma, Alfred-Nobel-Straße 10, 40789 Monheim am Rhein, Germany.
| | | | - Julie A Varner
- UCB Pharma, 8010 Arco Corporate Drive, Raleigh, NC 27617, USA.
| | - Brian D Moseley
- University of Cincinnati, 260 Stetson Street, Suite 2300, Cincinnati, OH 45267-0525, USA.
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Owusu KA, Dhakar MB, Bautista C, McKimmy D, Cotugno S, Sukumar N, Deng Y, Farooque P, Hirsch LJ, Maciel CB. Comparison of intranasal midazolam versus intravenous lorazepam for seizure termination and prevention of seizure clusters in the adult epilepsy monitoring unit. Epilepsy Behav 2019; 98:161-167. [PMID: 31374472 DOI: 10.1016/j.yebeh.2019.07.021] [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: 06/09/2019] [Revised: 07/05/2019] [Accepted: 07/05/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective of the study was to compare the performance of intravenous (IV) lorazepam (IVL) and intranasal midazolam (INM) for seizure termination and prevention of seizure clusters in adults admitted to the epilepsy monitoring unit (EMU) in whom seizures were captured on continuous video-electroencephalogram. METHODS Retrospective cohort of consecutive adults (≥18 years) with epilepsy admitted to the EMU at a single tertiary academic center, who experienced epileptic seizures (confirmed electroencephalographically) and required rescue therapy. The study spanned from January 2015 until December 2016, which included one year before and one year after transitioning from IVL to INM as the standard rescue therapy at our institution. RESULTS A total of 50 subjects received rescue therapy and were included in the analysis. In the first year, out of 216 patients with epilepsy admitted to the EMU, 27 (13%) received IVL; in the second year, 23/217 (11%) received INM. There were no differences in baseline characteristics and markers of epilepsy severity, the median duration of index seizure (1.7 min [interquartile range (IQR): 1.1-2.7] in IVL vs. 2.0 min [IQR: 1.5-2.6] in INM group, p = 0.20), or in the number of subjects requiring repeat benzodiazepine administrations (IVL 8/27 [29.6%] vs. INM 7/23 [30.4%], p = 0.95). There were no differences in the median number of recurrent seizures in 24 h (1 [IQR: 1-3] in IVL vs. 2 [IQR: 1-4] in INM, p = 0.27), occurrence of status epilepticus (IVL 4/27 [14.8%] subjects vs. INM 1/23 [4.3%] subjects, p = 0.36), incidence of seizure clusters (IVL 8/27 [29.6%] subjects vs. INM 7/23 [30.4%] subjects, p = 0.95), need for transfer to an intensive care unit (ICU), or other adverse events. SIGNIFICANCE In our retrospective study, INM was comparable with IVL for seizure termination and prevention of seizure clusters in the adult EMU. Intranasal midazolam circumvents the need for IV access to be maintained throughout hospitalization and is an attractive alternative to IVL as a rescue therapy in this setting. Ideally, future large, prospective, randomized, and double blind studies are needed to confirm these findings.
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Affiliation(s)
- Kent A Owusu
- Yale New Haven Health, Department of Pharmacy, 20 York Street, New Haven, CT 6510, United States of America; Yale New Haven Health, Office of Strategy Management, 200 Orchard Street, New Haven, CT 06511, United States of America.
| | - Monica B Dhakar
- Division of Epilepsy, Department of Neurology, Emory University School of Medicine, Atlanta, GA 30322, United States of America; Department of Neurology, Yale School of Medicine, New Haven, CT 06510, United States of America
| | - Cynthia Bautista
- Department of Emergency & Psychiatric Services, Yale-New Haven Hospital, New Haven, CT 06510, United States of America
| | - Dani McKimmy
- Department of Pharmacy, University of Florida Health, Gainesville, FL 32610, United States of America
| | - Stephanie Cotugno
- Emergency Department, Department of Pharmacy, University of Pittsburgh Medical Center, Shadyside Hospital, Pittsburgh, PA 15232, United States of America
| | - Nitin Sukumar
- Yale Center for Analytical Sciences, Yale University School of Public Health, New Haven, CT 06510, United States of America
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale University School of Public Health, New Haven, CT 06510, United States of America
| | - Pue Farooque
- Department of Neurology, Yale School of Medicine, New Haven, CT 06510, United States of America; Yale Comprehensive Epilepsy Center, Yale School of Medicine, New Haven, CT 06510, United States of America
| | - Lawrence J Hirsch
- Department of Neurology, Yale School of Medicine, New Haven, CT 06510, United States of America; Yale Comprehensive Epilepsy Center, Yale School of Medicine, New Haven, CT 06510, United States of America
| | - Carolina B Maciel
- Department of Neurology, Yale School of Medicine, New Haven, CT 06510, United States of America; Division of Neurocritical Care, Department of Neurology, University of Florida College of Medicine, Gainesville, FL 32610, United States of America
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Detyniecki K, Van Ess PJ, Sequeira DJ, Wheless JW, Meng TC, Pullman WE. Safety and efficacy of midazolam nasal spray in the outpatient treatment of patients with seizure clusters-a randomized, double-blind, placebo-controlled trial. Epilepsia 2019; 60:1797-1808. [PMID: 31140596 PMCID: PMC9291143 DOI: 10.1111/epi.15159] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 04/15/2019] [Indexed: 12/22/2022]
Abstract
Objective To evaluate the safety and efficacy of a novel formulation of midazolam administered as a single‐dose nasal spray (MDZ–NS) in the outpatient treatment of patients experiencing seizure clusters (SCs). Methods This was a phase III, randomized, double‐blind, placebo‐controlled trial (ClinicalTrials.gov NCT01390220) with patients age ≥12 years on a stable regimen of antiepileptic drugs. Following an in‐clinic test dose phase (TDP), patients entered an outpatient comparative phase (CP) and were randomized (2:1) to receive double‐blind MDZ–NS 5 mg or placebo nasal spray, administered by caregivers when they experienced an SC. The primary efficacy end point was treatment success (seizure termination within 10 minutes and no recurrence 10 minutes to 6 hours after trial drug administration). Secondary efficacy end points were proportion of patients with seizure recurrence 10 minutes to 4 hours, and time‐to‐next seizure >10 minutes after double‐blind drug administration. Safety was monitored throughout. Results Of 292 patients administered a test dose, 262 patients were randomized, and 201 received double‐blind treatment for an SC (n = 134 MDZ–NS, n = 67 placebo, modified intent‐to‐treat population). A significantly greater proportion of MDZ–NS‐ than placebo‐treated patients achieved treatment success (53.7% vs 34.4%; P = 0.0109). Significantly, fewer MDZ–NS‐ than placebo‐treated patients experienced seizure recurrence (38.1% vs 59.7%; P = 0.0043). Time‐to‐next seizure analysis showed early separation (within 30 minutes) between MDZ–NS and placebo that was maintained throughout the 24‐hour observation period (21% difference at 24 hours; P = 0.0124). Sixteen patients (5.5%) discontinued because of a treatment‐emergent adverse event (TEAE) during the TDP and none during the CP. During the CP, 27.6% and 22.4% of patients in the MDZ–NS and placebo groups, respectively, experienced ≥1 TEAE. Significance MDZ–NS was superior to placebo in providing rapid, sustained seizure control when administered to patients experiencing an SC in the outpatient setting and was associated with a favorable safety profile.
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Affiliation(s)
- Kamil Detyniecki
- Department of Neurology, Yale Comprehensive Epilepsy Center, Yale School of Medicine, New Haven, Connecticut
| | | | | | - James W Wheless
- Le Bonheur Comprehensive Epilepsy Program & Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, Tennessee.,Pediatric Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
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