Magnesium as an Effective Adjunct Therapy for Drug Resistant Seizures

Adrenocorticotropic hormone combined with magnesium sulfate therapy for infantile epileptic spasms syndrome: a real-world study

BACKGROUND

Infantile epileptic spasms syndrome (IESS) is a serious disease in infants, and it usually evolves to other epilepsy types or syndromes, especially refractory or super-refractory focal epilepsies. Although adrenocorticotropic hormone (ACTH) is one of the first-line and effective treatment plans for IESS, it has serious side effects and is not sufficiently effective.

METHODS

A retrospective study of the clinical outcomes of ACTH combined with magnesium sulfate (MgSO4) therapy for IESS in two hospital centers was conducted. The major outcome of the single and combined treatment was evaluated by changes in seizure frequency and improvements in hypsarrhythmia electroencephalography (EEG). To reduce the confounding bias between the two groups, we used SPSS for the propensity score matching (PSM) analysis.

RESULTS

We initially recruited 1205 IESS patients from two Chinese hospitals and treated them with ACTH combined with MgSO4 and ACTH alone. Only 1005 patients were enrolled in the treatment (ACTH combined with MgSO4: 744, ACTH: 261), and both treatment plans had a more than 55% response rate. However, compared to patients treated with ACTH alone, those patients treated with ACTH combined with MgSO4 had better performance in terms of the seizure frequency and hypsarrhythmia EEG. After PSM, the two groups also showed significant differences in responder rate [70.8% (95% confidence interval, CI) = 66.7%-74.8%) vs. 53.8% (95% CI = 47.4%-60.2%), P < 0.001], seizure frequency (P < 0.001) and hypsarrhythmia EEG resolution (P < 0.001). Notably, multivariate analysis revealed that the lead time to treatment and the number of antiseizure medications taken before treatment were two factors that may affect the clinical outcome. Patients with less than 3 months of lead time responded to the treatment much better than those with > 3 months (P < 0.05). In addition, the overall incidence of adverse reactions in the ACTH combined with MgSO4 group was much lower than that in the ACTH group (31.4% vs. 63.1%, P < 0.001). During the treatment, only infection (P = 0.045) and hypertension (P = 0.025) were significantly different between the two groups, and no baby died.

CONCLUSION

Our findings support that ACTH combined with MgSO4 is a more effective short-term treatment protocol for patients with IESS than ACTH alone, especially for those patients with short lead times to treatment. Video Abstract (MP4 533623 KB).

The Impact of Chronic Magnesium Deficiency on Excitable Tissues-Translational Aspects

Neuromuscular excitability is a vital body function, and Mg2+ is an essential regulatory cation for the function of excitable membranes. Loss of Mg2+ homeostasis disturbs fluxes of other cations across cell membranes, leading to pathophysiological electrogenesis, which can eventually cause vital threat to the patient. Chronic subclinical Mg2+ deficiency is an increasingly prevalent condition in the general population. It is associated with an elevated risk of cardiovascular, respiratory and neurological conditions and an increased mortality. Magnesium favours bronchodilation (by antagonizing Ca2+ channels on airway smooth muscle and inhibiting the release of endogenous bronchoconstrictors). Magnesium exerts antihypertensive effects by reducing peripheral vascular resistance (increasing endothelial NO and PgI2 release and inhibiting Ca2+ influx into vascular smooth muscle). Magnesium deficiency disturbs heart impulse generation and propagation by prolonging cell depolarization (due to Na+/K+ pump and Kir channel dysfunction) and dysregulating cardiac gap junctions, causing arrhythmias, while prolonged diastolic Ca2+ release (through leaky RyRs) disturbs cardiac excitation-contraction coupling, compromising diastolic relaxation and systolic contraction. In the brain, Mg2+ regulates the function of ion channels and neurotransmitters (blocks voltage-gated Ca2+ channel-mediated transmitter release, antagonizes NMDARs, activates GABAARs, suppresses nAChR ion current and modulates gap junction channels) and blocks ACh release at neuromuscular junctions. Magnesium exerts multiple therapeutic neuroactive effects (antiepileptic, antimigraine, analgesic, neuroprotective, antidepressant, anxiolytic, etc.). This review focuses on the effects of Mg2+ on excitable tissues in health and disease. As a natural membrane stabilizer, Mg2+ opposes the development of many conditions of hyperexcitability. Its beneficial recompensation and supplementation help treat hyperexcitability and should therefore be considered wherever needed.

The impact of serum magnesium and calcium on the risk of epilepsy: A mendelian randomization study

AIMS

To investigate the causal role of serum magnesium and calcium in epilepsy or any of its subtypes through Mendelian randomization (MR) approach.

METHODS

Single nucleotide polymorphisms (SNPs) associated with serum magnesium and calcium were used as the instrumental variables. MR analyses were performed using the summary-level data for epilepsy extracted from International League Against Epilepsy Consortium (15,212 cases and 29,677 controls) to obtain the causal estimates. The analyses were replicated using FinnGen data (7224 epilepsy cases and 208,845 controls), and a meta-analysis was then conducted.

RESULTS

The result of combined analyses showed that higher serum magnesium concentrations was associated with a reduced risk of overall epilepsy (odds ratios [OR] = 0.28, 95% confidence interval [CI], 0.12-0.62, p = 0.002). In ILAE, higher serum magnesium was suggestively associated with reduced risks of focal epilepsy (OR = 0.25, 95% CI 0.10-0.62, p = 0.003). However, the results cannot be repeated in sensitivity analyses. As for serum calcium, the results did not reach statistical significance with overall epilepsy (OR = 0.60, 95% CI, 0.31-1.17, p = 0.134). However, genetically predicted serum calcium concentrations showed an inverse association with risk of generalized epilepsy (OR = 0.35, 95% CI, 0.17-0.74, p = 0.006).

CONCLUSION

The current MR analysis did not support a causal relationship between serum magnesium and epilepsy, but showed a causally negative association between genetically determined serum calcium and generalized epilepsy.

A Mini Review on the Various Facets Effecting Brain Delivery of Magnesium and Its Role in Neurological Disorders

Magnesium is an essential cation present in the body that participates in the regulation of various vital body functions. Maintaining normal level of magnesium is essential for proper brain functions by regulating the activities of numerous neurotransmitters and their receptors. Various studies have been reported that magnesium level is found to be declined in both neurological and psychiatric diseases. Declined magnesium level in the brain initiates various cumbersome effects like excitotoxicity, altered blood-brain permeability, oxidative stress, and inflammation, which may further worsen the disease condition. Shreds of evidence from the experimental and clinical studies proved that exogenous administration of magnesium is useful for correcting disease-induced alterations in the brain. But one of the major limiting factors in the use of magnesium for treatment purposes is its poor blood-brain barrier permeability. Various approaches like the administration of its organic salts as pidolate and threonate forms, and the combination with polyethylene glycol or mannitol have been tried to improve its permeability to make magnesium as a suitable drug for different neurological disorders. These results have shown their experimental efficacy in diseased animal models, but studies regarding the safety and efficacy in human subjects are currently underway. We present a comprehensive review on the role of magnesium in the maintenance of normal functioning of the brain and various approaches for improving its BBB permeability.

Antiepileptic effects of cobalt, manganese and magnesium on bicuculline-induced epileptiform activity in hippocampal neurons

BACKGROUND

Calcium signaling is described as a relevant factor in synchronization of neurons and increased excitability in epileptogenesis. Aim of the present investigations was to test the antiepileptic effect of the classical inorganic calcium channel blockers cobalt (Co²⁺), manganese (Mn²⁺) and magnesium (Mg²⁺).

METHODS

Experiments were carried out on hippocampal slices of guinea pigs. Epileptiform field potentials (EFP) were elicited by adding bicuculline (10 µmol/l) to the artificial cerebrospinal fluid (CSF). Kalium was elevated from normal (4 mmol/l) to 8 mmol/l. Co²⁺ (CoCl₂; 2, 1, 0.5 and 0.1 mmol/l), Mn²⁺ (MnCl₂; 2, 1, 0.5 and 0.1 mmol/l) and Mg²⁺ (MgCl₂; 8, 6, 5, 4 and 2 mmol/l) were added to the superfusate.

RESULTS

Concentrations of 2, 1 and 0.5 mmol/l Co²⁺, 2 and 1 mmol/l Mn²⁺ and 8 respectively 6 mmol/l Mg²⁺ were able to suppress EFP sufficient in a dose dependent manner. In concentrations of 0.1 mmol/l Co²⁺, 0.5 mmol/l and 0.1 mmol/l Mn²⁺ and 5 respectively 4 and 2 mmol/l Mg²⁺ suppression was incomplete. With washout of the inorganic calcium channel blockers the EFP reappeared.

DISCUSSION

All tree inorganic calcium channel blockers were able to suppress EFP in a dosage dependent and reversible manner. Weak reappearance of EFP after washout of Co²⁺ might be due to additional cytotoxic effects. The following mechanisms may contribute: i) blockade of voltage-activated calcium channels in the postsynaptic membrane, ii) changes in the activation of voltage-dependent sodium channels, iii) blockade of synaptic transmission.

Risk of low serum levels of ionized magnesium in children with febrile seizure

Background

Suboptimal intake of magnesium become prevalent due to the modern diet of processed food low in magnesium. Magnesium may modulate seizure activity by antagonizing excitatory calcium influx through the N-methyl-D-aspartate receptor. Although hyponatremia has been reported to be common in febrile seizures, the most common form of seizure, little is known about the status of serum ionized magnesium. We therefore investigated the status of serum ionized magnesium (iMg²⁺) in children with febrile seizures and compared with controls.

Methods

We included all patients from 1 to 6 years old who had presented with febrile seizure to the pediatric emergency department at the Korea University Guro Hospital from July 2016 to February 2017. The control group comprised patients admitted to the hospital with febrile respiratory tract infections, but with no history of febrile seizure. Clinical data, blood tests, and electroencephalogram (EEG) results were reviewed using the patients’ medical records.

Results

A total of 133 patients with febrile seizure and 141 control patients were analyzed in the present study. As a result, hypomagnesemia (< 0.50 mmol/L) was more common in patients with febrile seizure than in controls (42.9% vs. 6.9%, p < 0.001) and it was an independent risk factor for febrile seizure (OR, odds ratio = 22.12, 95% CI = 9.23–53.02, P < 0.001). A receiver operating curve analysis revealed that serum iMg²⁺ levels < 0.51 mmol/L predicted the presence of febrile seizures with a sensitivity of 45.1% and a specificity of 92.6% (AUC, area under the curve = 0.731, 95% confidence interval = 0.671–0.791). When the patients with febrile seizure were divided in terms of a serum iMg²⁺ concentration of 0.51 mmol/L, there was no difference in clinical features.

Conclusions

Hypomagnesemia was more common and serum iMg²⁺ level was lower in patients with febrile seizures than in controls. However, further evidence is needed for the causal relationship between low magnesium and febrile convulsions.

Dietary intake of magnesium and the risk of epilepsy in middle-aged and older Finnish men: A 22-year follow-up study in a general population

OBJECTIVES

Magnesium may play an important role in the prevention or treatment of epilepsy. We aimed to examine the association between dietary intake of magnesium and the incidence of epilepsy in middle-aged Finnish men in a prospective setting. As a secondary analysis, we also considered a possible association between dietary intake of magnesium and inflammation in subjects with epilepsy.

METHODS

The study included 2442 men, ages 42 to 60 y, from the prospective Kuopio Ischaemic Heart Disease Risk Factor Study who were free of epilepsy at baseline between 1984 and 1989. Dietary intake of magnesium was assessed with a 4-d food record. The hospital discharge diagnosis of epilepsy was used as an outcome variable.

RESULTS

During the average follow-up period of 22.4 y, 74 men (3%) developed epilepsy. Those who followed the recommended dietary intake (>350 mg/d) of magnesium had a lower risk of epilepsy (hazard ratio [HR]: 0.52; confidence interval [CI], 0.28-0.99; P = 0.045) after multivariate adjustments. However, the risk was not significant after adjustment for C-reactive protein (CRP). We also found that CRP concentration was directly associated with the risk of epilepsy (HR: 1.24; CI, 1.00-1.54; P = 0.048). This association was attenuated after adjustment for dietary intake of magnesium and no longer significantly associated with the risk of epilepsy (HR: 1.22; CI, 0.99-1.52; P = 0.07).

CONCLUSIONS

A higher dietary intake of magnesium was associated with lower incident epilepsy, and this association was slightly mediated by CRP. Further studies are required to identify the potential mechanisms.

Magnesium and Human Health: Perspectives and Research Directions

Magnesium is the fourth most abundant cation in the body. It has several functions in the human body including its role as a cofactor for more than 300 enzymatic reactions. Several studies have shown that hypomagnesemia is a common electrolyte derangement in clinical setting especially in patients admitted to intensive care unit where it has been found to be associated with increase mortality and hospital stay. Hypomagnesemia can be caused by a wide range of inherited and acquired diseases. It can also be a side effect of several medications. Many studies have reported that reduced levels of magnesium are associated with a wide range of chronic diseases. Magnesium can play important therapeutic and preventive role in several conditions such as diabetes, osteoporosis, bronchial asthma, preeclampsia, migraine, and cardiovascular diseases. This review is aimed at comprehensively collating the current available published evidence and clinical correlates of magnesium disorders.

An acidosis-sparing ketogenic (ASK) diet to improve efficacy and reduce adverse effects in the treatment of refractory epilepsy

Diets that increase production of ketone bodies to provide alternative fuel for the brain are evolving from the classic ketogenic diet for epilepsy devised nearly a century ago. The classic ketogenic diet and its more recent variants all appear to have similar efficacy with approximately 50% of users showing a greater than 50% seizure reduction. They all require significant medical and dietetic support, and there are tolerability issues. A review suggests that low-grade chronic metabolic acidosis associated with ketosis is likely to be an important contributor to the short term and long term adverse effects of ketogenic diets. Recent studies, particularly with the characterization of the acid sensing ion channels, suggest that chronic metabolic acidosis may increase the propensity for seizures. It is also known that low-grade chronic metabolic acidosis has a broad range of negative health effects and an increased risk of early mortality in the general population. The modified ketogenic dietary treatment we propose is formulated to limit acidosis by measures that include monitoring protein intake and maximizing consumption of alkaline mineral-rich, low carbohydrate green vegetables. We hypothesize that this acidosis-sparing ketogenic diet is expected to be associated with less adverse effects and improved efficacy. A case history of life-long intractable epilepsy shows this diet to be a successful long-term strategy but, clearly, clinical studies are needed.

Addressing potential role of magnesium dyshomeostasis to improve treatment efficacy for epilepsy: A reexamination of the literature

Magnesium (Mg(2+) ) is an abundant mineral in the body serving many biochemical functions. Magnesium supplementation has been shown to raise seizure threshold in animal and human studies, but the etiological contribution of magnesium deficiency to the onset and maintenance of epilepsy, as well as the degree to which it impacts antiepileptic drug efficacy, remains poorly understood. This may be due, at least in part, to the inherent limitations of commonly used serum levels as a measure of functional magnesium status, as well as insufficient data regarding relative bioavailabilities of various magnesium salts and chelates for use with humans. To date, 1 randomized clinical trial has been conducted assessing Mg(2+) supplementation in epilepsy, and findings yielded promising results. Yet a notable dearth in the literature remains, and more studies are needed. To better understand the potential role of magnesium deficiency as a causal factor in epilepsy, more convenient and accurate measurement methods should to be developed and employed in randomized, controlled trials of oral magnesium supplementation in epilepsy. Findings from such studies have the potential to facilitate far-reaching clinical and economic improvements in epilepsy treatment standards.

Common variants associated with general and MMR vaccine-related febrile seizures

Febrile seizures represent a recognized serious adverse event following measles, mumps, and rubella (MMR) vaccination. We conducted a series of genome-wide association scans comparing children with MMR-related febrile seizures, children with febrile seizures unrelated to vaccination, and controls with no history of febrile seizures. Two loci were distinctly associated with MMR-related febrile seizures, harboring the interferon-stimulated gene IFI44L (rs273259; P = 5.9×10⁻¹² vs. controls; P =1.2×10⁻⁹ vs. MMR-unrelated febrile seizures) and the measles virus receptor CD46 (rs1318653; P = 9.6×10⁻¹¹ vs. controls; P = 1.6×10⁻⁹ vs. MMR-unrelated febrile seizures). Furthermore, four loci were associated with febrile seizures in general implicating the sodium channel genes SCN1A (rs6432860; P = 2.2×10⁻¹⁶) and SCN2A (rs3769955; P = 3.1×10⁻¹⁰), a TMEM16 family gene (TMEM16C; rs114444506; P = 3.7×10⁻²⁰), and a region associated with magnesium levels (12q21.33; rs11105468; P = 3.4×10⁻¹¹). Finally, functional relevance of TMEM16C was demonstrated with electrophysiological experiments in wild-type and knockout rats.

A review of traditional and novel treatments for seizures in autism spectrum disorder: findings from a systematic review and expert panel

Despite the fact that seizures are commonly associated with autism spectrum disorder (ASD), the effectiveness of treatments for seizures has not been well studied in individuals with ASD. This manuscript reviews both traditional and novel treatments for seizures associated with ASD. Studies were selected by systematically searching major electronic databases and by a panel of experts that treat ASD individuals. Only a few anti-epileptic drugs (AEDs) have undergone carefully controlled trials in ASD, but these trials examined outcomes other than seizures. Several lines of evidence point to valproate, lamotrigine, and levetiracetam as the most effective and tolerable AEDs for individuals with ASD. Limited evidence supports the use of traditional non-AED treatments, such as the ketogenic and modified Atkins diet, multiple subpial transections, immunomodulation, and neurofeedback treatments. Although specific treatments may be more appropriate for specific genetic and metabolic syndromes associated with ASD and seizures, there are few studies which have documented the effectiveness of treatments for seizures for specific syndromes. Limited evidence supports l-carnitine, multivitamins, and N-acetyl-l-cysteine in mitochondrial disease and dysfunction, folinic acid in cerebral folate abnormalities and early treatment with vigabatrin in tuberous sclerosis complex. Finally, there is limited evidence for a number of novel treatments, particularly magnesium with pyridoxine, omega-3 fatty acids, the gluten-free casein-free diet, and low-frequency repetitive transcranial magnetic simulation. Zinc and l-carnosine are potential novel treatments supported by basic research but not clinical studies. This review demonstrates the wide variety of treatments used to treat seizures in individuals with ASD as well as the striking lack of clinical trials performed to support the use of these treatments. Additional studies concerning these treatments for controlling seizures in individuals with ASD are warranted.