The outcomes of childhood convulsive status epilepticus

Enteral Ketamine for Status Epilepticus in Children with Epilepsy

BACKGROUND

Approximately 10% to 20% of children with epilepsy experience status epilepticus (SE), and children with seizure clustering are at higher risk. Ketamine is growing in use for SE. This study examines the efficacy and safety of enteral ketamine in the treatment of convulsive status epilepticus (CSE) characterized by refractory seizure clusters and nonconvulsive status epilepticus (NCSE) in children with epilepsy.

METHODS

Patient charts were reviewed retrospectively. Children with epilepsy aged one to 21 years presenting in SE and treated with enteral ketamine between September 1, 2021 and September 1, 2022 at a pediatric tertiary care center were identified. Resolution or reduction in seizure frequency within 48 hours, clinical presentation, endotracheal intubation, hospitalization duration, side effects, and readmission were assessed.

RESULTS

Nine patients aged two to 21 years were identified. Six patients presented in CSE characterized by recurrent seizures, and three patients presented in NCSE. Five patients had genetic epilepsies, including PCDH19- and MECP2-related epilepsy. Seven patients had resolution or reduction in seizures within 48 hours of ketamine initiation. Two patients were intubated. Hospitalization duration ranged from one to 34 days. Three patients reported side effects. Three patient readmissions with early ketamine treatment had equal or shorter hospitalizations.

CONCLUSIONS

Enteral ketamine may prove an effective, well-tolerated option for treatment of convulsive and nonconvulsive SE in children with epilepsy, including genetic epilepsies, and may prevent intubation and shorten hospitalization time.

Management of febrile convulsion in home settings: a qualitative study of multiple caregiver practices in the Cape Coast Metropolis in Ghana

BACKGROUND

Febrile convulsion (FC) among children is a common emergency concern received in hospitals and clinics. However, in Ghana, FC is commonly perceived as a non-hospital disease and usually managed at home. There is limited research on the home management of FC. This study, therefore, explored the home management of FC.

METHODS

The study design was a descriptive and interpretive phenomenology. Data sources were triangulated among 42 participants across 5 communities within 2 km distance from regional hospitals in the Cape Coast Metropolis. Participants were purposively selected and interviewed face to face in their homes and treatment centres using semistructured interview guides. Interviews were transcribed and thematically analysed with QSR NVivo V.14.

RESULTS

Three themes were identified from the inductive analysis. These themes were treatment, prevention and case referral. Subthemes on treatment were tepid sponging with lukewarm water, the use of herbal medicine and spiritual approaches. FC was referred to as 'asram suro'. The 'asram' literally means the moon, and 'suro' connotes the skies, indicating possibly that the condition emanates from a god of the moon. Caregivers prevented FC through behavioural approaches, herbal medicine, and mystical approaches including making scarification and tying amulets and beads particularly on the child's face and wrists respectively. FC cases were referred for clinical attention after home care resulted in undesirable treatment outcomes. A conceptual framework depicting the decision-making and practices towards FC management is presented.

CONCLUSION

FC is commonly managed at home independent of orthodox care availability. Caregivers employed herbal and ad hoc treatment regimens, usually unwarranted, visually frightening and spiritual approaches which were not the best home management approaches. These findings call for the need to educate caregivers about the best home management of FC.

Reducing epilepsy diagnostic and treatment gaps: Standardized paediatric epilepsy training courses for health care professionals

AIM

To evaluate improvement in knowledge and clinical behaviour among healthcare professionals after attendance at paediatric epilepsy training (PET) courses.

METHOD

Since 2005, 1-day PET courses have taught evidence-based paediatric epilepsy management to doctors and nurses in low-, middle-, and high-income countries. A cohort study was performed of 7528 participants attending 252 1-day PET courses between 2005 and 2020 in 17 low-, middle-, and high-income countries, and which gathered data from participants immediately after the course and then 6 months later. Training outcomes were measured prospectively in three domains (reaction, learning, and behaviour) using a mixed-methods approach involving a feedback questionnaire, a knowledge quiz before and after the course, and a 6-month survey.

RESULTS

Ninety-eight per cent (7217 of 7395) of participants rated the course as excellent or good. Participants demonstrated knowledge gain, answering a significantly higher proportion of questions correctly after the course compared to before the course (88% [47 883 of 54 196], correct answers/all quiz answers, vs 75% [40 424 of 54 196]; p < 0.001). Most survey responders reported that the course had improved their epilepsy diagnosis and management (73% [311 of 425]), clinical service (68% [290 of 427]), and local epilepsy training (68% [290 of 427]).

INTERPRETATION

This was the largest evaluation of a global epilepsy training course. Participants reported high course satisfaction, showed knowledge gain, and described improvements in clinical behaviour 6 months later. PET supports the global reduction in the epilepsy 'treatment gap' as promoted by the World Health Organization.

Aetiology and Outcome of Childhood Convulsive Status Epilepticus: A tertiary care experience in Oman

Objectives

This study aimed to evaluate the aetiology, management and outcomes of convulsive status epilepticus (CSE) in children and highlight the factors influencing patient outcomes in such cases.

Methods

In a retrospective study spanning the 2020-2023 period, 93 children with CSE treated at Sultan Qaboos University Hospital's emergency department (ED), high dependency unit (HDU) and intensive care unit (ICU) were analysed. The Modified Rankin Scale at discharge was used to determine CSE outcomes.

Results

Among the 93 children studied (mean age 4.84 ± 3.64 years), predominantly Omani (92.47%), 14 aetiologies were noted. Of them, acute symptomatic (37.7%) and febrile status (31.2%) were the primary causes of CSE. Diazepam was administered as the first-line treatment in 58 (67.44%) cases, with a median seizure duration of 45 minutes. Successful seizure control was achieved in 71 (76.34%) cases within 60 minutes. A return to baseline was observed in 55.9% of cases, while mortality and disability were noted in 5.38% and 38.7% of cases, respectively. For 17 cases, aetiology and duration significantly impacted patient outcomes (P <0.05).

Conclusion

Acute symptomatic status is the most common aetiology of CSE. A longer duration of CSE is associated with higher mortality and neurological disability. Prompt and appropriate management of CSE is essential. Furthermore, identifying and treating the underlying cause of CSE is a crucial step in reducing its duration and improving patient outcomes.

Survey of Pediatric Status Epilepticus Treatment Practices and Adherence to Management Guidelines (Pedi-SPECTRUM e-Survey)

Aim

Survey of treatment practices and adherence to pediatric status epilepticus (PSE) management guidelines in India.

Methods

This eSurvey was conducted over 35 days (15th October to 20th November 2023) and included questions related to hospital setting; antiseizure medications (ASMs); ancillary treatment; facilities available; etiology; and adherence to PSE management guidelines.

Results

A total of 170 respondents participated, majority of them were working in tertiary level hospitals (94.1%) as pediatric intensivists (56.5%) and pediatricians (19.4%), and were in clinical practice for 2-10 years (46.5%). Majority use intravenous (IV) midazolam and levetiracetam as first- and second-line ASMs (67.1 and 51.2%, respectively). In cases with refractory status epilepticus (RSE), the most commonly used ASM is midazolam infusion (92.4%). For super-refractory status epilepticus (SRSE), the commonly used third-line ASMs include midazolam infusion (34.1%), thiopentone infusion (26.5%), high dose phenobarbitone (18.2%), and ketamine infusion (15.3%). Overall, in cases with SRSE, 44.7% respondents use ketamine infusion, 42.5% use add-on oral topiramate, and 34.7% use high-dose phenobarbitone (1-3 mg/kg/hour) infusion. Most respondents targeted both clinical and EEG seizure control (48.8%). Ancillary treatment used for SRSE included IV pyridoxine (57.1%), methylprednisolone (45.3%), IVIG (42.4%), ketogenic diet (40.6%), and second-line immunomodulation (33.5%). Most common causes were febrile SE, viral encephalitis, and febrile illness-related epilepsy syndrome (60.6%, 52.4%, and 37.1%, respectively). Facilities available included pediatric intensive care units (PICU) (97.1%), mechanical ventilation (98.2%), pediatric neurologist (68.8%), MRI brain (86.5%), EEG (69.4%), and viral PCR (58.2%). The compliance with guidelines for timing of initiation of ASM ranged from 63.5 to 88.8%.

Conclusion

Intravenous midazolam bolus/es, levetiracetam, and midazolam infusion are commonly used first-, second-, and third-line ASMs, respectively. There were wide variations in use of ASMs for RSE and SRSE, ancillary treatment, and compliance to PSE management guidelines.

How to cite this article

Suthar R, Angurana SK, Nallasamy K, Bansal A, Muralidharan J. Survey of Pediatric Status Epilepticus Treatment Practices and Adherence to Management Guidelines (Pedi-SPECTRUM e-Survey). Indian J Crit Care Med 2024;28(5):504-510.

Prophylactic antiseizure medications for recurrent status epilepticus in nonsyndromic childhood epilepsy

PURPOSE

The management of status epilepticus (SE) has mainly focused on the termination of ongoing SE episodes. However, long-term therapeutic strategies for the prevention of SE are lacking. This study aimed to investigate the effectiveness of prophylactic antiseizure medications (ASMs) for SEs in nonsyndromic childhood epilepsy.

METHODS

This retrospective study was conducted at Jikei University Hospital. Patients <18 years of age, diagnosed with epilepsy, and experiencing three or more SE episodes within 1 year between April 1, 2017, and October 1, 2021, were included. ASMs introduced for seizure types that developed into SE were evaluated. The effectiveness of ASMs was determined by using the "Rule of Three": An ASM was determined effective if patients were free of SE for a duration at least three times that of their longest SE interval in 12 months prior to intervention.

RESULTS

The investigation included a total of 32 ASMs administered to 13 patients. The longest interval between SE episodes before ASM administration was 28-257 d. The first SE interval after ASM administration was 12-797 d. Levetiracetam (LEV) and clobazam (CLB) showed effectiveness in 2/10 and 5/6 patients, respectively. Other ASMs were ineffective. The leading etiology of epilepsy was perinatal brain injury, identified in four patients, and CLB was effective in all of them.

CONCLUSIONS

The present study suggests that CLB and LEV may prolong the SE interval in some cases of nonsyndromic childhood epilepsy. CLB may be beneficial, particularly in patients with perinatal brain injury.

Early Clinical Variables Associated With Refractory Convulsive Status Epilepticus in Children

BACKGROUND AND OBJECTIVES

The objective of this study was to determine patient-specific factors known proximate to the presentation to emergency care associated with the development of refractory convulsive status epilepticus (RSE) in children.

METHODS

An observational case-control study was conducted comparing pediatric patients (1 month-21 years) with convulsive SE whose seizures stopped after benzodiazepine (BZD) and a single second-line antiseizure medication (ASM) (responsive established status epilepticus [rESE]) with patients requiring more than a BZD and a single second-line ASM to stop their seizures (RSE). These subpopulations were obtained from the pediatric Status Epilepticus Research Group study cohort. We explored clinical variables that could be acquired early after presentation to emergency medical services with univariate analysis of the raw data. Variables with p < 0.1 were retained for univariable and multivariable regression analyses. Multivariable logistic regression models were fit to age-matched and sex-matched data to obtain variables associated with RSE.

RESULTS

We compared data from a total of 595 episodes of pediatric SE. Univariate analysis demonstrated no differences in time to the first BZD (RSE 16 minutes [IQR 5-45]; rESE 18 minutes [IQR 6-44], p = 0.068). Time to second-line ASM was shorter in patients with RSE (RSE 65 minutes; rESE 70 minutes; p = 0.021). Both univariable and multivariable regression analyses revealed a family history of seizures (OR 0.37; 95% CI 0.20-0.70, p = 0.0022) or a prescription for rectal diazepam (OR 0.21; 95% CI 0.078-0.53, p = 0.0012) was associated with decreased odds of RSE.

DISCUSSION

Time to initial BZD or second-line ASM was not associated with progression to RSE in our cohort of patients with rESE. A family history of seizures and a prescription for rectal diazepam were associated with a decreased likelihood of progression to RSE. Early attainment of these variables may help care for pediatric rESE in a more patient-tailored manner.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that patient and clinical factors may predict RSE in children with convulsive seizures.

Status Epilepticus in Chromosomal Disorders Associated with Epilepsy: A Systematic Review

Status Epilepticus (SE) is a neurological emergency resulting from the failure of mechanisms of seizure termination or from the initiation of mechanisms that lead to prolonged seizures. The International League Against Epilepsy (ILAE) identified 13 chromosomal disorders associated with epilepsy (CDAE); data regarding SE occurrence in these patients is lacking. A systematic scoping review was conducted to outline current literature evidence about clinical features, treatments, and outcomes of SE in pediatric and adult patients with CDAE. A total of 373 studies were identified with the initial search; 65 of these were selected and regarded as SE in Angelman Syndrome (AS, n = 20), Ring 20 Syndrome (R20, n = 24), and other syndromes (n = 21). Non-convulsive status epilepticus (NCSE) is frequently observed in AS and R20. No specific, targeted therapies for SE in CDAE are available to date; anecdotal reports about SE treatment are described in the text, as well as various brief- and long-term outcomes. Further evidence is needed to precisely portray the clinical features, treatment options, and outcomes of SE in these patients.

Status epilepticus following vaccination in children aged ≤24 months: A five-year retrospective observational study

BACKGROUND

Status epilepticus is associated with significant morbidity and mortality. While vaccine-proximate status epilepticus (VP-SE) has rarely been associated with cases of Dravet syndrome, it is not known whether VP-SE differs clinically from non-vaccine proximate status epilepticus (NVP-SE).

METHODS

Medical records of children aged ≤24 months, presenting to one of five Australian tertiary pediatric hospitals with their first episode of status epilepticus from 2013 to 2017 were identified using ICD-coded discharge diagnoses. Vaccination history was obtained from the Australian Immunisation Register. Hospitalization details, subsequent epilepsy diagnosis, and vaccination uptake were compared between VP-SE and NVP-SE cases.

RESULTS

Of 245 first status epilepticus hospitalization with immunization records, 35 (14%) were VP-SE and 21 (60%) followed measles-containing vaccines. Vaccine-proximate status epilepticus cases had a median age of 12.5 months [IQR 7.1-14.73], 23 (66%) were in males, 15 (43%) were febrile status epilepticus and 17 (49%) had an infection confirmed. There were no significant differences in hospitalization duration (P = 0.50) or intensive care unit admission (P = 0.42) between children with VP-SE compared to children with NVP-SE. Children with no history of seizures at their first VP-SE had longer hospitalizations, were more likely to require intensive care unit admission, but were less likely to have a subsequent diagnosis of epilepsy than children with previous seizures at their first VP-SE.

CONCLUSION

First VP-SE was predominantly associated with a measles-containing vaccine at 12-months of age. Seizure severity was no different between first VP-SE and first NVP-SE. In children with VP-SE, subsequent seizure admissions and epilepsy diagnosis were associated with having seizure prior to their first SE.

Specific characteristics and current diagnostic and treatment modalities performance of super refractory status epilepticus in children: A comparative study

OBJECTIVE

Super-refractory status epilepticus (SRSE) is associated with significant morbidity and mortality in children. We explored the clinical spectrum, specific characteristics, and outcome in SRSE patients admitted in a pediatric intensive care unit (PICU) and investigated how well current diagnostic or treatment modalities perform compared to Status Epilepticus (SE) and Refractory SE (RSE) patients.

METHODS

Retrospective analysis of PICU patients admitted with convulsive SE during 2009-2019. Eighty-six patients were classified as SE, RSE, and SRSE. New-onset RSE (NORSE) and febrile infection-related epilepsy syndrome (FIRES) were also identified. Functional outcome was evaluated by the modified Rankin scale.

RESULTS

Patients with SRSE (n = 20) had longer weaning off anesthetics (p = 0.014), length of stay, mechanical ventilation duration, higher illness severity scores, and poorer outcome compared to SE (n = 13) or RSE (n = 53) patients (all p < 0.001). Diagnosis, mainly expressed by high prevalence of NORSE (n = 13) and FIRES (n = 9), was independently associated with SRSE (p = 0.024). Abnormal MRI findings (p = 0.005), and epilepsy-related pathogenic variants identified by whole-exome sequencing (WES) were mostly found in SRSE patients. Compared to intravenous immunoglobulins and steroid pulses, plasmapheresis and ketogenic diet, more often used in SRSE (p < 0.01), contributed better to seizure control. Only SRSE (AUROC > 0.80, 95% CI = 0.68-0.94, p < 0.001) and diagnosis (AUROC > 0.70, 95% CI = 0.55-0.83, p = 0.02) could predict a poor outcome.

CONCLUSION

The majority of SRSE patients are characterized by considerable functional decline and morbidity. WES analysis may reveal epilepsy-related pathogenic variants while early aggressive immunotherapy and/or ketogenic diet might prove beneficial. Multicenter studies for prediction models of outcome are needed.

Disability and Mortality in Convulsive Status Epilepticus in Children at 3 Months' Follow-Up: A Prospective Study from India

Background  Convulsive status epilepticus (CSE) is a common neurological emergency with high mortality, morbidity, and poor quality of life. There is a paucity of follow-up studies from developing nations in pediatric age group.

Objectives  This article looks for clinico-etiological profile of CSE and estimates the immediate and short-term mortality in children with CSE and its predictive factors.

Methodology  This prospective longitudinal study was done at a tertiary care institute of Northern India. The patients between the ages of 1 and 16 years with CSE were enrolled after informed consent, they were observed in the hospital, and survived patients were followed till 3 months after discharge.

Results  A total of 200 patients (58% males) were enrolled. Acute symptomatic (63.5%) was the most common etiology. Twenty-five (12.5%) patients died during hospital stay; at discharge, 160 (80%) had good recovery and rest had a varying range of disability. The predictive factors for poor outcome were female gender, duration of CSE > 1 hour at presentation, generalized seizures, Glasgow Coma Scale < 8 at presentation, refractory status epilepticus, need for critical care support, and acute symptomatic etiology. On follow-up, two patients died at 1-month and one at 3-month follow-up, the cause of death was probably seizures in two patients and feed aspiration in one patient. Seven patients deteriorated from good recovery scoring to moderate disability during the time interval between first and second follow-up, none of them reported apparent repeat seizures.

Conclusion  Pediatric CSE is associated with immediate poor outcome; risk of death and new disabilities persist after discharge thus proper follow-up is essential.

Nonshared environmental factors in the aetiology of autism and other neurodevelopmental conditions: a monozygotic co-twin control study

Background

A significant proportion of variation in likelihood of neurodevelopmental conditions (NDCs) has been attributed to nonshared environmental (NSE) factors, although it remains unclear which NSE factors pose specific risks for certain NDCs.

Methods

A monozygotic co-twin design was applied in a sample of 224 twins (mean age = 17.70 years, SD = 6.28) controlling for confounders such as genes and shared environment. Generalized estimating equation models were fitted, using perinatal and postnatal indications of NSEs as exposure, operationalized both as separate risk factors and as cumulative risk loads. Categorical and dimensional operationalizations of autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), intellectual disability and other NDCs were used as outcomes.

Results

Birth weight discordance was associated with dimensional autism and ADHD for the smaller twin, and medication during infancy was associated with dimensional autism. Among postnatal factors scarlet fever during early childhood was associated with lower IQ. Especially autism was associated with a greater cumulative perinatal or postnatal risk load.

Limitations

When exploring the associations between each condition and specific NSEs the risk of being statistically underpowered increases. Hence, we limit the reported findings on specific indicators of NSEs to trait levels and present descriptive data for categorical NDCs.

Conclusions

The findings support previous research by indicating an association between exposure to perinatal and postnatal risks and subsequent NDCs within twin pairs and suggest that autism may be especially linked to accumulative early environmental risks. The findings are potentially important for developmental outcomes prognoses and may inform targeted prevention and early interventions.

Perceived causes and diagnosis of febrile convulsion in selected rural contexts in Cape Coast Metropolis, Ghana

BACKGROUND

Febrile convulsion (FC) is a common seizure disorder among children aged 9 months to 5 years. It is usually benign and self-limiting with favourable prognosis. However, in Ghana, FC is commonly perceived as "not for hospital" and widely diagnosed and managed at home based on several beliefs and practices which are limited in related literature.

OBJECTIVE

This study explored the perceived causes and diagnosis of FC in selected rural communities in the Cape Coast Metropolis, Ghana.

METHODS

A descriptive phenomenological study design underpinned the study at five selected communities located not more than 2 Kilometres from the University of Cape Coast Hospital. Purposive and snowball sampling techniques were used to interview 42 participants made up of 27 parents, two grandmothers, seven registered traditional health practitioners, four herbalists, and two faith healers in the communities. The data was analysed using QSR NVivo 12.

RESULTS

Three perceived causes of FC were identified - biological, social/behavioural, and spiritual. Biological causes include genetic abnormalities and other underlying health conditions. The behavioural factors include poor childcare practices and nutrition. Spiritual causes include harm caused by evil spirits. The diagnosis of FC were observed prior, during and after FC attack, and these includes high body temperature, extreme body jerking, and disability outcomes respectively.

CONCLUSION

The perceived causes of FC are interplay of complex natural, social and spiritual factors that were deep-rooted in local socio-cultural beliefs and FC experiences. Unlike the attack stage, pre-attack diagnosis were usually missed, or misconstrued to mean other health conditions. These findings indicate the need to intensify maternal and child health (MCH) education programmes on FC in the study area through improved primary healthcare.

Levetiracetam Versus Phenytoin or Fosphenytoin for Second-Line Treatment of Pediatric Status Epilepticus: A Meta-Analysis

OBJECTIVE

To synthesize the available evidence examining the efficacy and safety of levetiracetam compared with phenytoin or fosphenytoin in benzodiazepine-refractory pediatric status epilepticus.

DATA SOURCES

We searched (from inception until April 27, 2020) Ovid MEDLINE, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials.

STUDY SELECTION

Two reviewers, independently and in duplicate, screened citations and manuscripts for eligible randomized controlled trials.

DATA EXTRACTION AND SYNTHESIS

Independently and in duplicate, we performed data abstraction, risk of bias assessment, and certainty assessment using Grading of Recommendations, Assessment, Development, and Evaluation. We performed meta-analyses using random-effect models or, if insufficient data, presented findings narratively.

RESULTS

We identified seven randomized controlled trials (n = 1,575). Pooled analysis demonstrated low certainty evidence for no difference of levetiracetam on time to seizure cessation (mean difference, -3.11 min; 95% CI, -6.67 to 0.45), early seizure cessation (relative risk, 1.09, 95% CI, 0.95-1.26), or late seizure cessation (relative risk, 1.05; 95% CI, 0.93-1.18). Adverse event outcomes were limited by low event numbers. We found low certainty evidence for less respiratory depression with levetiracetam (relative risk, 0.28; 95% CI, 0.12-0.69).

CONCLUSIONS

The efficacy of levetiracetam is comparable with phenytoin or fosphenytoin in children with benzodiazepine-refractory status epilepticus (low certainty evidence). Levetiracetam may cause less respiratory depression. Clinicians and guideline developers should weigh safety profiles when choosing between these agents.

Initial treatment of seizures in children in an emergency department in rural Japan

OBJECTIVE

Although the initial treatment of childhood seizures is important, treatment within an appropriate time window is often difficult in resource-limited areas. This study examined childhood seizure treatment in a rural area in Japan.

METHODS

We retrospectively investigated children presenting to Nakatsugawa Municipal General Hospital emergency department between 2015 and 2018. From the hospital database, we identified children who were diagnosed with seizures, epilepsy, or acute infectious encephalitis/encephalopathy or were given benzodiazepines. We considered etiology, seizure duration, and treatment according to the specialties of the doctors providing initial care.

RESULTS

We extracted 236 seizure events: 40 initially treated by pediatricians, 16 by a mobile doctor team, and 180 by other doctors. Twenty patients had continuous seizures for longer than 5 min on admission. Two were treated by pediatricians at presentation; it took 4 and 7 min after arrival to stop the seizures. Four were treated by a mobile team, and 14 by other doctors; the median response times were 11.5 (range 3-47) and 19 (range 5-60) min, respectively. All patients treated by pediatricians or mobile doctor teams received intravenous or intramuscular diazepam, whereas 50% of those treated by other doctors initially received diazepam suppositories. In three of the 20 events, establishing intravenous access was difficult.

SIGNIFICANCE

In rural Japan, many children with seizures are initially treated by doctors other than pediatricians or emergency physicians, and they require a longer time to achieve seizure cessation. Non-intravenous benzodiazepine formulas, which have not yet been approved in Japan, would be helpful.

Status Epilepticus in Children

For various reasons, status epilepticus in children is different than in adults. Pediatric specificities include status epilepticus epidemiology, underlying etiologies, pathophysiological mechanisms, and treatment options. Relevant data from the literature are presented for each of them, and questions remaining open for future studies on status epilepticus in childhood are listed.

Therapeutic advances in Dravet syndrome: a targeted literature review

INTRODUCTION

Dravet syndrome (DS), a prototypic developmental and genetic epileptic encephalopathy (DEE), is characterized by an early onset of treatment-refractory seizures, together with impairments in motor control, behavior, and cognition. Even with multiple conventional anti-epileptic drugs, seizures remain poorly controlled, and there has been a considerable unmet need for effective and tolerable treatments.

AREAS COVERED

This targeted literature review aims to highlight recent changes to the therapeutic landscape for DS by summarizing the most up-to-date, evidence-based research, including pivotal data from the clinical development of stiripentol, cannabidiol, and fenfluramine, which are important milestones for DS treatment, together with the latest findings of other pharmacotherapies in development. In phase III, double-blind, placebo-controlled randomized controlled trials stiripentol, cannabidiol, and fenfluramine have shown clinically relevant reductions in convulsive seizure frequency, and are generally well tolerated. Stiripentol was associated with responder rates (greater than 50% reduction in convulsive seizure frequency) of 67%-71%, when added to valproic acid and clobazam; cannabidiol was associated with responder rates of 43%-49% (48%-63% in conjunction with clobazam), and fenfluramine of 54%-68% across studies. Therapies in development include soticlestat, ataluren, verapamil, and clemizole, with strategies to treat the underlying cause of DS, including gene therapy and antisense oligonucleotides beginning to emerge from preclinical studies.

EXPERT OPINION

Despite the challenges of drug development in rare diseases, this is an exciting time for the treatment of DS, with the promise of new efficacious and well-tolerated therapies, which may pave the way for treatment advances in other DEEs.