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Lindquist BE, Timbie C, Voskobiynyk Y, Paz JT. Thalamocortical circuits in generalized epilepsy: Pathophysiologic mechanisms and therapeutic targets. Neurobiol Dis 2023; 181:106094. [PMID: 36990364 PMCID: PMC10192143 DOI: 10.1016/j.nbd.2023.106094] [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: 12/23/2022] [Revised: 02/02/2023] [Accepted: 03/19/2023] [Indexed: 03/29/2023] Open
Abstract
Generalized epilepsy affects 24 million people globally; at least 25% of cases remain medically refractory. The thalamus, with widespread connections throughout the brain, plays a critical role in generalized epilepsy. The intrinsic properties of thalamic neurons and the synaptic connections between populations of neurons in the nucleus reticularis thalami and thalamocortical relay nuclei help generate different firing patterns that influence brain states. In particular, transitions from tonic firing to highly synchronized burst firing mode in thalamic neurons can cause seizures that rapidly generalize and cause altered awareness and unconsciousness. Here, we review the most recent advances in our understanding of how thalamic activity is regulated and discuss the gaps in our understanding of the mechanisms of generalized epilepsy syndromes. Elucidating the role of the thalamus in generalized epilepsy syndromes may lead to new opportunities to better treat pharmaco-resistant generalized epilepsy by thalamic modulation and dietary therapy.
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Affiliation(s)
- Britta E Lindquist
- UCSF Department of Neurology, Division of Neurocritical Care, United States of America; UCSF Department of Neurology, Division of Pediatric Epilepsy, United States of America; UCSF Department of Neurology, United States of America
| | - Clare Timbie
- Gladstone Institute of Neurological Disease, United States of America; UCSF Department of Neurology, Division of Pediatric Epilepsy, United States of America; UCSF Department of Neurology, United States of America
| | - Yuliya Voskobiynyk
- Gladstone Institute of Neurological Disease, United States of America; UCSF Department of Neurology, United States of America
| | - Jeanne T Paz
- Gladstone Institute of Neurological Disease, United States of America; UCSF Department of Neurology, United States of America; Kavli Institute for Fundamental Neuroscience, UCSF, United States of America.
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Nucera B, Brigo F, Trinka E, Kalss G. Treatment and care of women with epilepsy before, during, and after pregnancy: a practical guide. Ther Adv Neurol Disord 2022; 15:17562864221101687. [PMID: 35706844 PMCID: PMC9189531 DOI: 10.1177/17562864221101687] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 05/03/2022] [Indexed: 01/16/2023] Open
Abstract
Women with epilepsy (WWE) wishing for a child represent a highly relevant subgroup of epilepsy patients. The treating epileptologist needs to delineate the epilepsy syndrome and choose the appropriate anti-seizure medication (ASM) considering the main goal of seizure freedom, teratogenic risks, changes in drug metabolism during pregnancy and postpartum, demanding for up-titration during and down-titration after pregnancy. Folic acid or vitamin K supplements and breastfeeding are also discussed in this review. Lamotrigine and levetiracetam have the lowest teratogenic potential. Data on teratogenic risks are also favorable for oxcarbazepine, whereas topiramate tends to have an unfavorable profile. Valproate needs special emphasis. It is most effective in generalized seizures but should be avoided whenever possible due to its teratogenic effects and the negative impact on neuropsychological development of in utero-exposed children. Valproate still has its justification in patients not achieving seizure freedom with other ASMs or if a woman decides to or cannot become pregnant for any reason. When valproate is the most appropriate treatment option, the patient and caregiver must be fully informed of the risks associated with its use during pregnancies. Folate supplementation is recommended to reduce the risk of major congenital malformations. However, there is insufficient information to address the optimal dose and it is unclear whether higher doses offer greater protection. There is currently no general recommendation for a peripartum vitamin K prophylaxis. During pregnancy most ASMs (e.g. lamotrigine, oxcarbazepine, and levetiracetam) need to be increased to compensate for the decline in serum levels; exceptions are valproate and carbamazepine. Postpartum, baseline levels are reached relatively fast, and down-titration is performed empirically. Many ASMs in monotherapy are (moderately) safe for breastfeeding and women should be encouraged to do so. This review provides a practically oriented overview of the complex management of WWE before, during, and after pregnancy.
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Affiliation(s)
- Bruna Nucera
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Centre for Cognitive Neuroscience, Member of the ERN EpiCARE, Salzburg, Austria
| | - Gudrun Kalss
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Centre for Cognitive Neuroscience, Member of the ERN EpiCARE, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria
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3
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French JA, Wechsler RT, Trinka E, Brandt C, O'Brien TJ, Patten A, Salah A, Malhotra M. Long-term open-label perampanel: generalized tonic-clonic seizures in idiopathic generalized epilepsy. Epilepsia Open 2022; 7:393-405. [PMID: 35445567 PMCID: PMC9436298 DOI: 10.1002/epi4.12602] [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: 11/09/2021] [Revised: 04/01/2022] [Accepted: 04/09/2022] [Indexed: 11/26/2022] Open
Abstract
Objective Assess the longer‐term efficacy and safety of adjunctive perampanel (up to 12 mg/day) in patients aged ≥12 years with generalized tonic–clonic (GTC) seizures from the Open‐label Extension (OLEx) Phase of Study 332 to determine whether responses obtained during the Core Study are maintained during long‐term treatment. Methods Patients with GTC seizures previously enrolled in a randomized placebo‐controlled trial of perampanel could enter an OLEx Phase comprising 6‐week blinded conversion (during which patients previously randomized to placebo‐switched to perampanel) and up to 136‐week maintenance periods (maximum perampanel dose of 12 mg/day). A 4‐week follow‐up period was completed by all patients after the last on‐treatment visit during the OLEx. We assessed seizure frequency outcomes from preperampanel baseline and the Core Study Pre‐randomization Phase, retention rates, doses selected, and treatment‐emergent adverse events (TEAEs). Results Overall, 138 patients entered the OLEx. Median percent reductions in GTC seizures per 28 days from preperampanel were 77% (Weeks 1‐13) and 90% (Weeks 40‐52). Retention rates were 88% (6 months) and 75% (12 months). Seizure‐freedom rates were maintained for at least 2 years regardless of prior treatment received during the Core Study. Most common modal daily dose was >4‐8 mg/day (n = 93). Across the Core and OLEx Phases, 120 (87%) patients experienced TEAEs; the most common was dizziness. Significance Perampanel was generally well‐tolerated, and the TEAEs reported here are consistent with the known safety profile of perampanel. Perampanel offers a long‐term treatment option for patients (aged ≥12 years) with GTC seizures.
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Affiliation(s)
| | | | - Eugen Trinka
- Department of Neurology, Member of the European Reference Network EpiCare, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Pracelsus Medical University, Salzburg, Austria.,Neuroscience Institute, Christian Doppler Medical Centre, Paracelsus Medical University and Centre for Cognitive Neuroscience, Salzburg, Austria.,Karl Landsteiner Institute for Neurorehabilitation and Space Neurology, Salzburg, Austria.,Department of Public Health, UMIT-University for Health Sciences, Medical Informatics and Technology, Eduard-Wallnöfer-Zentrum 1, Hall in Tirol, Austria
| | - Christian Brandt
- Bethel Epilepsy Center, University Hospital for Epileptology, Bielefeld, Germany
| | - Terence J O'Brien
- The Royal Melbourne Hospital, The University of Melbourne, Parkville, Australia
| | - Anna Patten
- Eisai Europe Ltd., Hatfield, Hertfordshire, UK
| | - Alejandro Salah
- Formerly: Eisai Inc., Nutley, NJ, USA; 11Eisai Inc., Nutley, NJ, USA
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Alicino AM, Falcicchio G, Boero G, Santarcangelo G, Francavilla T, Trojano M, La Neve A. Perampanel during pregnancy: Description of four cases. Epilepsy Behav Rep 2021; 16:100490. [PMID: 34761195 PMCID: PMC8567359 DOI: 10.1016/j.ebr.2021.100490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/15/2021] [Accepted: 09/26/2021] [Indexed: 11/30/2022] Open
Abstract
Perampanel (PER) is approved in Italy as an adjunctive treatment for focal-onset seizures (FOS) and generalized tonic-clonic seizures (GTCs), and it could be an alternative to valproate in young women diagnosed with idiopathic generalized epilepsy. Nevertheless, clinical data about the outcome of pregnancies in women exposed to PER are lacking. Here, we report retrospectively collected data from four women suffering from FOS who were exposed to PER during pregnancy. Three pregnancies were carried out with PER as add-on therapy during the entire gestation (8 mg/day in two patients and 6 mg/day in one), without seizure frequency variations. The fourth patient started PER 2 mg/day as monotherapy during the 13th week of pregnancy due to seizure relapse and continued it until delivery with complete seizure control. All pregnancies showed good outcomes, and their newborns did not possess major congenital malformations. Apgar scores and auxological parameters at birth were normal. Fetal pathology in follow-up during pregnancies was absent in all cases. In our patients PER was well tolerated and appeared safe for the fetuses and did not result in major malformations or adverse events at birth. Nevertheless, this is a report involving a small number of patients and it does not suggest the general use of PER is safe during pregnancy.
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Affiliation(s)
- A M Alicino
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - G Falcicchio
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - G Boero
- Complex Structure of Neurology, SS Annunziata Hospital, Taranto, Italy
| | | | - T Francavilla
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - M Trojano
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - A La Neve
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
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Sannagowdara K, Khan N. Medical Management in Focal versus Generalized Epilepsy. JOURNAL OF PEDIATRIC EPILEPSY 2021. [DOI: 10.1055/s-0040-1722297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AbstractAbout 70% of children with new-onset epilepsy have the potential to become seizure-free on antiepileptic drug (AED) monotherapy with appropriately selected first-line medication. In ideal world, physician is expected to achieve best possible seizure control without impacting the quality of life. There is rapid increase in number of AEDs available over last couple of decades. Although not necessarily all of them are superior to old generation drugs in terms of seizure control, certainly there is change in landscape from perspective of tolerability and side-effect profile. Physicians must therefore be familiar with safety, tolerability, therapeutic effects, synergistic combinations as well as AEDs to avoid in specific circumstances. The article attempts to give general overview of available AEDs under broad umbrella of effectiveness against focal and generalized seizures as well as drugs with “broad spectrum.” The emergence of newer AEDs with broad spectrum and favorable side-effect profile is welcome. However, the future lies in better understanding of underlying diverse pathophysiology of clinical symptom “epilepsy” and developing new compounds acting on molecular targets as well as individualizing therapy. Technological advances in molecular genetics research are bringing precision medicine to the fore.
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Affiliation(s)
- Kumar Sannagowdara
- Department of Child Neurology and Epilepsy, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Nadir Khan
- Department of Child Neurology and Epilepsy, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
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Outin H, Gueye P, Alvarez V, Auvin S, Clair B, Convers P, Crespel A, Demeret S, Dupont S, Engels JC, Engrand N, Freund Y, Gelisse P, Girot M, Marcoux MO, Navarro V, Rossetti A, Santoli F, Sonneville R, Szurhaj W, Thomas P, Titomanlio L, Villega F, Lefort H, Peigne V. Recommandations Formalisées d’Experts SRLF/SFMU : Prise en charge des états de mal épileptiques en préhospitalier, en structure d’urgence et en réanimation dans les 48 premières heures (A l’exclusion du nouveau-né et du nourrisson). ANNALES FRANCAISES DE MEDECINE D URGENCE 2020. [DOI: 10.3166/afmu-2020-0232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
La Société de réanimation de langue française et la Société française de médecine d’urgence ont décidé d’élaborer de nouvelles recommandations sur la prise en charge de l’état mal épileptique (EME) avec l’ambition de répondre le plus possible aux nombreuses questions pratiques que soulèvent les EME : diagnostic, enquête étiologique, traitement non spécifique et spécifique. Vingt-cinq experts ont analysé la littérature scientifique et formulé des recommandations selon la méthodologie GRADE. Les experts se sont accordés sur 96 recommandations. Les recommandations avec le niveau de preuve le plus fort ne concernent que l’EME tonico-clonique généralisé (EMTCG) : l’usage des benzodiazépines en première ligne (clonazépam en intraveineux direct ou midazolam en intramusculaire) est recommandé, répété 5 min après la première injection (à l’exception du midazolam) en cas de persistance clinique. En cas de persistance 5 min après cette seconde injection, il est proposé d’administrer la seconde ligne thérapeutique : valproate de sodium, (fos-)phénytoïne, phénobarbital ou lévétiracétam. La persistance avérée de convulsions 30 min après le début de l’administration du traitement de deuxième ligne signe l’EMETCG réfractaire. Il est alors proposé de recourir à un coma thérapeutique au moyen d’un agent anesthésique intraveineux de type midazolam ou propofol. Des recommandations spécifiques à l’enfant et aux autres EME sont aussi énoncées.
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Nishida T, Lee SK, Wu T, Tiamkao S, Dash A. Efficacy and safety of perampanel in generalized and focal to bilateral tonic-clonic seizures: A comparative study of Asian and non-Asian populations. Epilepsia 2020; 60 Suppl 1:47-59. [PMID: 30869168 DOI: 10.1111/epi.14644] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 12/13/2018] [Accepted: 12/18/2018] [Indexed: 11/27/2022]
Abstract
Perampanel is an approved adjunctive treatment for focal seizures with or without focal to bilateral tonic-clonic (FBTC) seizures and generalized tonic-clonic (GTC) seizures. We compared efficacy and safety of perampanel vs placebo in Asian and non-Asian populations in a post hoc analysis of pooled data from 5 randomized phase 3 studies. Patients (≥12 years old) with focal + FBTC seizures received perampanel 2, 4, 8, or 12 mg or placebo; patients with GTC seizures received perampanel 8 mg or placebo (titration: 4-6 weeks; maintenance: 13 weeks). Efficacy endpoints included median percentage change in FBTC or GTC seizure frequency per 28 days and 50% responder rate relative to baseline. Median percentage change in FBTC seizure frequency was significantly greater for perampanel 8 and 12 mg than placebo in the Asian population (median difference from placebo: -30.32%, P = 0.0017; -30.06%, P = 0.0008, respectively) and perampanel 4, 8, and 12 mg in the non-Asian population (-35.07%, P = 0.0001; -37.78%, P < 0.0001; -34.53%, P < 0.0001, respectively). In both populations, median percentage change in GTC seizure frequency was significantly greater for perampanel 8 mg than placebo (median difference from placebo: Asian, -37.37%, P = 0.0139; non-Asian, -27.04%, P = 0.0006). The 50% responder rates were significantly greater than placebo for perampanel 8 and 12 mg for FBTC seizures (Asian: 58.0%, P = 0.0017 and 58.6%, P = 0.0013, respectively; non-Asian: 59.3%, P < 0.0001 and 54.3%, P = 0.0050, respectively) and perampanel 8 mg for GTC seizures (Asian: 57.6%, P = 0.0209; non-Asian: 68.8%, P = 0.0329). Pooled FBTC/GTC seizure data showed generally similar patterns of response to perampanel in both populations. The most frequent treatment-related adverse events were fatigue, irritability, dizziness, somnolence, and headache. Perampanel was effective, well tolerated, and can be considered a therapeutic option for FBTC/GTC seizures in Asian populations.
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Affiliation(s)
- Takuji Nishida
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, National Hospital Organization, Shizuoka, Japan
| | - Sang Kun Lee
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Tony Wu
- Department of Neurology, Chang Gung Memorial Hospital and University, Taoyuan City, Taiwan
| | - Somsak Tiamkao
- Department of Medicine, Faculty of Medicine, Integrated Epilepsy Research Group, Khon Kaen University, Khon Kaen, Thailand
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Abstract
Common genetic generalised epilepsy syndromes encountered by clinicians include childhood and juvenile absence epilepsies, juvenile myoclonic epilepsy and generalised tonic-clonic seizures on awakening. Treatment of these syndromes involves largely the use of broad-spectrum antiseizure drugs. Those effective for the generalised epilepsies include sodium valproate, phenobarbital, ethosuximide, clobazam, clonazepam, lamotrigine, levetiracetam, topiramate, zonisamide and, more recently, perampanel and brivaracetam. Results from the few rigorous studies comparing outcomes with drugs for genetic generalised epilepsies show valproate to be the most effective. The majority of patients with genetic generalised epilepsy syndromes will become seizure free on antiseizure monotherapy; those for whom control proves elusive may benefit from combination regimens. Early counselling regarding management may assist the patient to come to terms with their diagnosis and improve long-term outcomes. Treatment can be lifelong in some individuals, although others may remain seizure free without medication. Choice of antiseizure medication depends on the efficacy for specific seizure types, as well as tolerability. For patients prescribed comedication, drug interactions should be considered. In particular, for young women taking oral hormonal contraceptives, ≥ 200 mg/day of topiramate can decrease the circulating concentration of ethinylestradiol and ≥ 12 mg/day of perampanel can induce levonorgestrel metabolism. The use of valproate in women of childbearing potential is limited by associated teratogenic and neurodevelopmental effects in offspring. Given that valproate is often the antiseizure drug of choice for genetic generalised epilepsies, this creates a dilemma for patients and clinicians. Decision making can be aided by comprehensive assessment and discussion of treatment options. Psychiatric comorbidities are common in adolescents and adults with genetic generalised epilepsies. These worsen the prognosis, both in terms of seizure control and quality of life. Attendant lifestyle issues can impact significantly on the individual and society. Frontal lobe dysfunction, which can present in patients with juvenile myoclonic epilepsy, can adversely affect the long-term outlook, regardless of the nature of seizure control. Ongoing management requires consideration of psychosocial and behavioural factors that can complicate diagnosis and treatment. An assured supportive attitude by the neurologist can be an important contributor to a positive outcome. The mechanisms underlying genetic generalised epilepsies, including genetic abnormalities, are unclear at present. As the pathophysiology is unravelled, this may lead to the development of novel therapies and improved outcomes for patients with these syndromes.
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Affiliation(s)
- Linda J Stephen
- West Glasgow Ambulatory Care Hospital, Dalnair St, Glasgow, G3 8SJ, UK.
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Khuda I, Aljaafari D. Epilepsy in pregnancy. A comprehensive literature review and suggestions for saudi practitioners. ACTA ACUST UNITED AC 2019; 23:185-193. [PMID: 30007993 PMCID: PMC8015586 DOI: 10.17712/nsj.2018.3.20180129] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
In the context of local culture and misconceptions regarding epilepsy, Saudi practitioners need a careful management plan for women with epilepsy that satisfies all the patients’ needs and ensures their spouses’ understanding. Such a management strategy needs to incorporate careful selection and monitoring of anti-epileptic drugs and regular counseling of patients. Female epileptic patients in the reproductive age group, no matter whether they are pregnant or not, should be managed by safest drugs from the earliest with folic acid supplementation along with adequate pre-marriage/conception counseling. All antiepileptic drugs are potentially teratogenic. However, valproic acid, phenytoin, phenobarbitone, and topiramate are least favored for use. Monotherapy is preferred over polytherapy, and the least possible dose should be used. During pregnancy, many epileptic women may need monthly drug level monitoring and dose readjustments. Normal vaginal delivery is safe in epileptic women. Post-partum follow-up with anti-epileptic drug titration may be required.
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Affiliation(s)
- Inam Khuda
- Department of Neurology, King Fahd Hospital of the University, Imam Abdulrahman bin Faisal University, Al-Khobar, Kingdom of Saudi Arabia. E-mail:
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Guidelines for seizure management in palliative care: proposal for an updated clinical practice model based on a systematic literature review. NEUROLOGÍA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.nrleng.2018.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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León Ruiz M, Rodríguez Sarasa M, Sanjuán Rodríguez L, Pérez Nieves M, Ibáñez Estéllez F, Arce Arce S, García-Albea Ristol E, Benito-León J. Guía para el manejo de las crisis epilépticas en cuidados paliativos: propuesta de un modelo actualizado de práctica clínica basado en una revisión sistemática de la literatura. Neurologia 2019; 34:165-197. [DOI: 10.1016/j.nrl.2016.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Revised: 11/23/2016] [Accepted: 11/24/2016] [Indexed: 01/19/2023] Open
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Potschka H, Trinka E. Perampanel: Does it have broad-spectrum potential? Epilepsia 2018; 60 Suppl 1:22-36. [PMID: 29953584 DOI: 10.1111/epi.14456] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2017] [Indexed: 12/26/2022]
Abstract
This article reviews the profile of perampanel, a novel noncompetitive α-amino-3-hydroxyl-5-methyl-4-isoxazole-propionate (AMPA) receptor antagonist, and its role as a potential broad-spectrum antiepileptic drug in the treatment of epilepsy. For this narrative review, data were collected using specified search criteria. Articles reporting the evidence for perampanel's efficacy from preclinical models, phase 3 clinical studies, observational studies, and descriptive evidence were included. AMPA receptors play a key role in mediating the action of glutamate at the excitatory synapse. Preclinical research showed the AMPA receptor blockade to constitute a promising target for antiepileptic drug therapy. In animal models, perampanel proved to be protective against seizures and reduce seizure severity and duration. Four phase-3 randomized controlled trials (3 in patients with focal seizures and one in primary generalized tonic-clonic seizures in idiopathic generalized epilepsy) have been completed. In focal (partial) onset seizures, perampanel (4, 8, and 12 mg) significantly reduced seizure frequency per 28 days (23.3%-28.8% vs 12.8%; P < .01) and responder rates (≥50% reduction in seizures) (28.5%-35.3% vs 19.3%; P < .05) compared with placebo. In primary generalized tonic-clonic seizures, perampanel 8 mg resulted in greater reduction in seizure frequency per 28 days (-76.5% vs -38.4%; P < .0001) and responder rate (64.2% vs 39.5%; P = .0019) than placebo. The efficacy, safety, and tolerability of perampanel have been reproduced in real-world clinical practice, and the agent has been shown to be effective in other epilepsy syndromes. Perampanel is a potentially broad-spectrum antiepileptic drug with a novel mechanism of action that may be a useful addition for patients with epilepsy with various seizure types. The availability of novel antiepileptic drugs for epilepsy treatment enables more individualized treatment for these patients.
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Affiliation(s)
- Heidrun Potschka
- Institute of Pharmacology, Toxicology and Pharmacy, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, University Hospital Paracelsus Medical University, Salzburg, Austria.,Institute of Public Health, Medical Decision Making and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology, UMIT, Hall in Tyrol, Austria
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Leo A, Giovannini G, Russo E, Meletti S. The role of AMPA receptors and their antagonists in status epilepticus. Epilepsia 2018; 59:1098-1108. [DOI: 10.1111/epi.14082] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2018] [Indexed: 01/08/2023]
Affiliation(s)
- Antonio Leo
- Department of Science of Health; University Magna Graecia of Catanzaro; Catanzaro Italy
| | - Giada Giovannini
- Department of Biomedical Metabolic and Neural Sciences; University of Modena and Reggio Emilia; Modena Italy
| | - Emilio Russo
- Department of Science of Health; University Magna Graecia of Catanzaro; Catanzaro Italy
| | - Stefano Meletti
- Department of Biomedical Metabolic and Neural Sciences; University of Modena and Reggio Emilia; Modena Italy
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LaPenna P, Tormoehlen LM. The Pharmacology and Toxicology of Third-Generation Anticonvulsant Drugs. J Med Toxicol 2017; 13:329-342. [PMID: 28815428 DOI: 10.1007/s13181-017-0626-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 07/09/2017] [Accepted: 07/12/2017] [Indexed: 10/19/2022] Open
Abstract
Epilepsy is a neurologic disorder affecting approximately 50 million people worldwide, or about 0.7% of the population [1]. Thus, the use of anticonvulsant drugs in the treatment of epilepsy is common and widespread. There are three generations of anticonvulsant drugs, categorized by the year in which they were developed and released. The aim of this review is to discuss the pharmacokinetics, drug-drug interactions, and adverse events of the third generation of anticonvulsant drugs. Where available, overdose data will be included. The pharmacokinetic properties of third-generation anticonvulsant drugs include relatively fewer drug-drug interactions, as well as several unique and life-threatening adverse events. Overdose data are limited, so thorough review of adverse events and knowledge of drug mechanism will guide expectant management of future overdose cases. Reporting of these cases as they occur will be necessary to further clarify toxicity of these drugs.
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Affiliation(s)
- Paul LaPenna
- Department of Neurology, Indiana University, 355 W. 16th Street, Suite 3200, Indianapolis, IN, 46202, USA
| | - Laura M Tormoehlen
- Department of Neurology, Indiana University, 355 W. 16th Street, Suite 3200, Indianapolis, IN, 46202, USA. .,Department of Emergency Medicine, Indiana University, Indianapolis, IN, USA.
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