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Solaz S, Cardenal-Muñoz E, Muñoz A, Giorgi S, Pallardó FV, Romá-Mateo C, Aibar JÁ. Navigating Dravet syndrome in Spain: A cross-sectional study of diagnosis, management, and care coordination. Epilepsia Open 2024. [PMID: 38984594 DOI: 10.1002/epi4.13012] [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: 04/05/2024] [Revised: 06/24/2024] [Accepted: 06/29/2024] [Indexed: 07/11/2024] Open
Abstract
OBJECTIVES Dravet syndrome (DS) is a rare form of refractory epilepsy that begins in the first year of life. Approximately 85% of patients have a mutation in the SCN1A gene, which encodes a voltage-gated sodium channel. The main objective of the present work was to assess the degree of knowledge of DS among Spanish primary care (PC) professionals, the communication flow between them and the pediatric neurologists (PNs), and the services available and resources offered to patients in Spain when searching for a diagnosis and adequate treatment. METHODS Two anonymized online surveys on DS diagnosis and patient management in PC were conducted with Spanish PC pediatricians (PCPs) and caregivers of DS patients in Spain. RESULTS Most PCPs are aware of genetic epilepsy but lack full knowledge of DS and patient advocacy groups (PAGs). Access to epilepsy treatments varies among regions, with many referrals to hospitals and pediatric neurologists. Diagnosis is often delayed, with misdiagnoses and frequent emergency room (ER) visits. Treatment involves multiple drugs, and sodium channel blockers are used, which are contraindicated in DS treatment. Improved training, resources, and communication are needed for early diagnosis. SIGNIFICANCE To improve the care and treatment of DS patients in Spain, early diagnosis is required and, possibly, specific efforts aimed at identifying patients in adulthood, generating socio-sanitary structures that integrate social and health services to provide comprehensive care, taking into account the different features and comorbidities of the disease. PLAIN LANGUAGE SUMMARY Dravet syndrome (DS) is a form of genetic epilepsy that starts within the first year of life. We present a study showing that, while family doctors are aware of genetic epilepsies, many don't have a complete understanding of DS. Unfortunately, getting the right diagnosis can take a long time, leading to unnecessary visits to the emergency room. Patients often need several medications, and sometimes they're given drugs that aren't recommended for DS. The takeaway is that training for doctors, more resources, and improved communication could help creating better healthcare systems and therefore give easier access to the right therapies.
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Affiliation(s)
- Sandra Solaz
- Departamento de Salud Hospital La Fe, Centro de Salud de Silla, Valencia, Spain
| | | | | | | | - Federico V Pallardó
- Department of Physiology, Faculty of Medicine and Dentistry, Universitat de València (UV), Valencia, Spain
- Center for Biomedical Network Research on Rare Diseases (CIBERER), Institute of Health Carlos III, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
| | - Carlos Romá-Mateo
- Department of Physiology, Faculty of Medicine and Dentistry, Universitat de València (UV), Valencia, Spain
- Center for Biomedical Network Research on Rare Diseases (CIBERER), Institute of Health Carlos III, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
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Wirrell EC, Lagae L, Scheffer IE, Cross JH, Specchio N, Strzelczyk A. Practical considerations for the use of fenfluramine to manage patients with Dravet syndrome or Lennox-Gastaut syndrome in clinical practice. Epilepsia Open 2024. [PMID: 38962968 DOI: 10.1002/epi4.12998] [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: 05/20/2024] [Accepted: 06/04/2024] [Indexed: 07/05/2024] Open
Abstract
Fenfluramine (FFA), an antiseizure medication (ASM) with serotonergic and sigma-1 receptor activity, is used to manage patients with developmental and epileptic encephalopathies (DEEs). It is approved in the US for treating seizures associated with Dravet syndrome (DS) and Lennox-Gastaut syndrome (LGS) in patients ≥2 years old and as add-on therapy for seizures associated with DS and LGS in the EU, UK, and Japan in similarly aged patients. Consensus guidelines for treatment of DS have recommended FFA to be an early-line ASM, and it has also shown efficacy in managing seizures associated with LGS. DS and LGS are DEEs associated with a range of seizure types, developmental impairments, and multiple comorbidities. Here we provide case vignettes describing 4 patients (3 DS and 1 LGS) aged 4-29 years old in whom up to 14 ASMs had previously failed, to illustrate real-world practice issues encountered by neurologists. This review provides guidance on the use of FFA in the context of ASM polytherapy and drug-drug interactions (DDIs), behavioral issues, dose titration, and adverse events. Along with data from the clinical trial program, these case vignettes emphasize the low risk of DDIs, a generally well-tolerated safety profile, and other seizure and nonseizure benefits (eg, improved cognition and sleep) associated with the use of FFA in DS or LGS. PLAIN LANGUAGE SUMMARY: Fenfluramine is used to treat seizures in individuals with Dravet syndrome and Lennox-Gastaut syndrome, but there are a range of issues that clinicians may face when treating patients. This review highlights four patients from the authors' everyday clinical work and offers guidance and practical considerations by neurologists with expertise in managing these complex conditions related to drug interactions, dosing, and side effects associated with fenfluramine.
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Affiliation(s)
- Elaine C Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lieven Lagae
- Member of the European Reference Network EpiCARE, Department of Pediatric Neurology, University of Leuven, Leuven, Belgium
| | - Ingrid E Scheffer
- Austin Hospital and Royal Children''s Hospital, Florey and Murdoch Children's Research Institutes, University of Melbourne, Melbourne, Victoria, Australia
| | - J Helen Cross
- Developmental Neurosciences Research & Teaching Department, UCL NIHR BRC Great Ormond Street Institute of Child Health, London, UK
- Department of Neurology, Great Ormond Street Hospital, London, UK
| | - Nicola Specchio
- Neurology, Epilepsy and Movement Disorders Unit, Bambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network EpiCARE, Rome, Italy
| | - Adam Strzelczyk
- Goethe-University Frankfurt, Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, University Hospital Frankfurt, Frankfurt am Main, Germany
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Torres-Fortuny A, Aras LM, Duñabeitia JA. Assessment of aggressive behavior in Dravet syndrome: a critical look. Front Integr Neurosci 2024; 18:1403681. [PMID: 38741918 PMCID: PMC11089182 DOI: 10.3389/fnint.2024.1403681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 04/16/2024] [Indexed: 05/16/2024] Open
Affiliation(s)
| | - Luis Miguel Aras
- Asociación ApoyoDravet, Donostia-San Sebastian, Spain
- Servicio Navarro de Salud-Osasunbidea, Pamplona, Spain
| | - Jon Andoni Duñabeitia
- Centro de Investigación Nebrija en Cognición (CINC), Universidad Nebrija, Madrid, Spain
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Pietrafusa N, Trivisano M, Casellato S, Correale C, Cappelletti S, De Liso P, Onida I, Sotgiu S, Butera A, Specchio N, Vigevano F. Fenfluramine below the age of 2 years in Dravet syndrome: What about safety and efficacy? Epilepsia 2024; 65:e7-e13. [PMID: 38065833 DOI: 10.1111/epi.17854] [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: 11/03/2023] [Revised: 12/06/2023] [Accepted: 12/07/2023] [Indexed: 12/22/2023]
Abstract
Dravet syndrome (DS) is a rare developmental and epileptic encephalopathy. Infants with DS are especially vulnerable to the detrimental effects of prolonged and frequent seizures on development. Fenfluramine (FFA) is approved for the treatment of DS in patients aged 2 years and older. This study aims to evaluate the safety and efficacy of FFA in patients with DS younger than 2 years. We analyzed safety, tolerability, seizure, and neuropsychological outcome in a real-world setting. Developmental profile was investigated using Griffiths Mental Development Scales (GMDS). Five patients received FFA at a mean age of 14.9 months (9.6-18.6). Median follow-up was 13 months (interquartile range [IQR] = 12.9-24.4). All patients showed good tolerance to FFA. No significant variation of body mass index or echocardiographic issue was observed. Monthly median convulsive seizure frequency (MCSF) was 1.71 (IQR = 1.56-3.27) at the 6-month baseline period and .92 (IQR = .43-1.28) at last follow-up, with a median 54.43 (IQR = 40.91-60.83) percentage reduction in MCSF. Two of five patients had a performance improvement on GMDS subscales. Overall, the use of FFA below the age of 2 years in our small sample of patients was safe and represents a promising opportunity for seizure control and for protection of the neurodevelopmental outcome.
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Affiliation(s)
- Nicola Pietrafusa
- Neurology, Epilepsy, and Movement Disorders Unit, Full Member of European Reference Network EpiCARE, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Marina Trivisano
- Neurology, Epilepsy, and Movement Disorders Unit, Full Member of European Reference Network EpiCARE, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Susanna Casellato
- Diagnosis and Treatment of Developmental Epilepsy, Child Neuropsychiatry Unit, Women and Children Department, AOU Sassari, Sassari, Italy
| | - Cinzia Correale
- Neurology, Epilepsy, and Movement Disorders Unit, Full Member of European Reference Network EpiCARE, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Simona Cappelletti
- Neurology, Epilepsy, and Movement Disorders Unit, Full Member of European Reference Network EpiCARE, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paola De Liso
- Neurology, Epilepsy, and Movement Disorders Unit, Full Member of European Reference Network EpiCARE, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Ilaria Onida
- Diagnosis and Treatment of Developmental Epilepsy, Child Neuropsychiatry Unit, Women and Children Department, AOU Sassari, Sassari, Italy
| | - Stefano Sotgiu
- Diagnosis and Treatment of Developmental Epilepsy, Child Neuropsychiatry Unit, Women and Children Department, AOU Sassari, Sassari, Italy
| | - Ambra Butera
- Neurology and Child Psychiatry Unit, Gaetano Barresi Department of Human Pathology of Adulthood and Development, University of Messina, Messina, Italy
| | - Nicola Specchio
- Neurology, Epilepsy, and Movement Disorders Unit, Full Member of European Reference Network EpiCARE, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Federico Vigevano
- Neurological Sciences and Rehabilitation Medicine Scientific Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Strzelczyk A, Lagae L, Wilmshurst JM, Brunklaus A, Striano P, Rosenow F, Schubert‐Bast S. Dravet syndrome: A systematic literature review of the illness burden. Epilepsia Open 2023; 8:1256-1270. [PMID: 37750463 PMCID: PMC10690674 DOI: 10.1002/epi4.12832] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/22/2023] [Indexed: 09/27/2023] Open
Abstract
We performed a systematic literature review and narrative synthesis according to a pre-registered protocol (Prospero: CRD42022376561) to identify the evidence associated with the burden of illness in Dravet syndrome (DS), a developmental and epileptic encephalopathy characterized by drug-resistant epilepsy with neurocognitive and neurobehavioral impairment. We searched MEDLINE, Embase, and APA PsychInfo, Cochrane's database of systematic reviews, and Epistemonikos from inception to June 2022. Non-interventional studies reporting on epidemiology (incidence, prevalence, and mortality), patient and caregiver health-related quality of life (HRQoL), direct and indirect costs and healthcare resource utilization were eligible. Two reviewers independently carried out the screening. Pre-specified data were extracted and a narrative synthesis was conducted. Overall, 49 studies met the inclusion criteria. The incidence varied from 1:15 400-1:40 900, and the prevalence varied from 1.5 per 100 000 to 6.5 per 100 000. Mortality was reported in 3.7%-20.8% of DS patients, most commonly due to sudden unexpected death in epilepsy and status epilepticus. Patient HRQoL, assessed by caregivers, was lower than in non-DS epilepsy patients; mean scores (0 [worst] to 100/1 [best]) were 62.1 for the Kiddy KINDL/Kid-KINDL, 46.5-54.7 for the PedsQL and 0.42 for the EQ-5D-5L. Caregivers, especially mothers, were severely affected, with impacts on their time, energy, sleep, career, and finances, while siblings were also affected. Symptoms of depression were reported in 47%-70% of caregivers. Mean total direct costs were high across all studies, ranging from $11 048 to $77 914 per patient per year (PPPY), with inpatient admissions being a key cost driver across most studies. Mean costs related to lost productivity were only reported in three publications, ranging from approximately $19 000 to $20 000 PPPY ($17 596 for mothers vs $1564 for fathers). High seizure burden was associated with higher resource utilization, costs and poorer HRQoL. The burden of DS on patients, caregivers, the healthcare system, and society is profound, reflecting the severe nature of the syndrome. Future studies will be able to assess the impact that newly approved therapies have on reducing the burden of DS.
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Affiliation(s)
- Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine‐Main, Center of Neurology and NeurosurgeryGoethe‐University and University Hospital FrankfurtFrankfurt am MainGermany
- LOEWE Center for Personalized and Translational Epilepsy Research (CePTER)Goethe‐University FrankfurtFrankfurt am MainGermany
| | - Lieven Lagae
- Department of Development and RegenerationUniversity Hospitals KU LeuvenLeuvenBelgium
| | - Jo M Wilmshurst
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, Neuroscience InstituteUniversity of Cape TownCape TownSouth Africa
| | - Andreas Brunklaus
- Paediatric Neurosciences Research GroupRoyal Hospital for ChildrenGlasgowUK
- School of Health and WellbeingUniversity of GlasgowGlasgowUK
| | - Pasquale Striano
- IRCCS ‘G. Gaslini’ InstituteGenovaItaly
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child HealthUniversity of GenoaGenovaItaly
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine‐Main, Center of Neurology and NeurosurgeryGoethe‐University and University Hospital FrankfurtFrankfurt am MainGermany
- LOEWE Center for Personalized and Translational Epilepsy Research (CePTER)Goethe‐University FrankfurtFrankfurt am MainGermany
| | - Susanne Schubert‐Bast
- Epilepsy Center Frankfurt Rhine‐Main, Center of Neurology and NeurosurgeryGoethe‐University and University Hospital FrankfurtFrankfurt am MainGermany
- LOEWE Center for Personalized and Translational Epilepsy Research (CePTER)Goethe‐University FrankfurtFrankfurt am MainGermany
- Department of NeuropediatricsGoethe‐University and University Hospital FrankfurtFrankfurt am MainGermany
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Wang Y, Xu S, Xiao Z, Jiang Y, Jiang Q, Li J, He W. Stiripentol Enteric Solid Dispersion-Loaded Effervescent Tablets: Enhanced Dissolution, Stability, and Absorption. AAPS PharmSciTech 2022; 23:141. [PMID: 35538376 DOI: 10.1208/s12249-022-02261-5] [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: 01/08/2022] [Accepted: 03/20/2022] [Indexed: 11/30/2022] Open
Abstract
Due to poor solubility and stability in acid conditions, the gastrointestinal administration of stiripentol (STP) is still a significant challenge. This study aimed to explore the applicability of effervescent tablets compressed from STP-loaded enteric solid dispersions to improve the solubility and stability of the insoluble and acid-labile drug. STP-loaded solid dispersions (STP-SDs) and the effervescent tablets (STP-SD-ETs) were prepared using solvent evaporation and dry granulation technology, respectively, and their formulations were optimized. Then, STP-SDs were characterized regarding solid state, in vitro release, stability, etc. Results showed that enteric amorphous STP-SDs were successfully prepared and significantly improved the solubility and stability of STP. Moreover, compared with STP suspensions, the bioavailability of STP-SD-ETs was as high as 138.71%. Concomitantly, STP-SD-ETs significantly increased the intestinal absorption rate of STP. Overall, the oral preparation encompassing enteric solid dispersion combined with effervescent tablet technology possesses excellent performance in enhancing dissolution, anti-acid hydrolysis stability, and absorption of STP. Our work provides a promising method to improve the delivery of drugs with poor solubility and acid-labile stability.
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Cardenal-Muñoz E, Auvin S, Villanueva V, Cross JH, Zuberi SM, Lagae L, Aibar JÁ. Guidance on Dravet syndrome from infant to adult care: Road map for treatment planning in Europe. Epilepsia Open 2021; 7:11-26. [PMID: 34882995 PMCID: PMC8886070 DOI: 10.1002/epi4.12569] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 11/24/2021] [Accepted: 12/02/2021] [Indexed: 12/22/2022] Open
Abstract
Dravet syndrome (DS) is a severe, rare, and complex developmental and epileptic encephalopathy affecting 1 in 16 000 live births and characterized by a drug‐resistant epilepsy, cognitive, psychomotor, and language impairment, and behavioral disorders. Evidence suggests that optimal treatment of seizures in DS may improve outcomes, even though neurodevelopmental impairments are the likely result of both the underlying genetic variant and the epilepsy. We present an updated guideline for DS diagnosis and treatment, taking into consideration care of the adult patient and nonpharmaceutical therapeutic options for this disease. This up‐to‐date guideline, which is based on an extensive review of the literature and culminates with a new treatment algorithm for DS, is a European consensus developed through a survey involving 29 European clinical experts in DS. This guideline will serve professionals in their clinical practice and, as a consequence, will benefit DS patients and their families.
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Affiliation(s)
- Elena Cardenal-Muñoz
- Dravet Syndrome Foundation Spain, Member of the EpiCARE ePAG Group, Madrid, Spain
| | - Stéphane Auvin
- APHP. Service de Neurologie Pédiatrique, Hôpital Robert Debré, Paris, France.,INSERM NeuroDiderot, Université de Paris, Paris, France.,Institut Universitaire de France (IUF), Paris, France
| | - Vicente Villanueva
- Refractory Epilepsy Unit, Hospital Universitario y Politécnico La Fe, Member of the ERN EpiCARE, Valencia, Spain
| | - J Helen Cross
- Department of Developmental Neurosciences, UCL NIHR BRC Great Ormond Street Institute of Child Health, London, UK.,Department of Neurology, Great Ormond Street Hospital for Children, Member of the ERN EpiCARE, London, UK
| | - Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Member of the ERN EpiCARE, Glasgow, UK.,Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - Lieven Lagae
- Department of Development and Regeneration, KU Leuven, Member of the ERN EpiCARE, Leuven, Belgium
| | - José Ángel Aibar
- Dravet Syndrome Foundation Spain, Member of the EpiCARE ePAG Group, Madrid, Spain
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