1
|
Bruschi G, Pellegrino L, Bisogno AL, Ferreri F, Kassabian B, Seppi D, Favaretto S, Corbetta M, Dainese F. Use of perampanel oral suspension for the treatment of refractory and super-refractory status epilepticus. Epilepsy Behav 2024; 156:109826. [PMID: 38761446 DOI: 10.1016/j.yebeh.2024.109826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/30/2024] [Accepted: 05/06/2024] [Indexed: 05/20/2024]
Abstract
INTRODUCTION Status epilepticus (SE) is a medical emergency associated with a significant risk of disability and death. The treatment of SE follows a step-wise approach, with limited data on ideal antiseizure medications (ASMs) for refractory and super refractory SE (RSE/SRSE). Perampanel (PER), an AMPA receptor antagonist, has shown promise in animal models but still has limited data in humans. This study tried to evaluate optimal dosage and safety of PER in RSE and SRSE patients. MATERIALS AND METHODS We retrospectively analysed 17 adult patients with RSE (1) or SRSE (16) treated with PER. Demographic and clinical data, including EEG patterns, ASMs administered, PER dosages, and PER plasma concentrations, were collected. For patients receiving a 24 mg PER loading dose (full dose group), the following treatment regimen was applied: 24 mg per day for 48 h following by 16 mg per day. The response to PER was assessed based on electroencephalographic (EEG) improvement from high to low epileptiform activity or from low to the absence of epileptiform activities. Safety was evaluated monitoring hepatic and renal function. RESULTS A response rate of 58.82 % was observed, with significantly higher responses in the full dose group (81.82 %) compared to those receiving PER doses below 24 mg (low dose group) (16.67 %) (p-value = 0.004; OR 0.044, 95 % CI 0.003 to 0.621, p = 0.021). No other clinical factors significantly influenced treatment response. Hepatic enzymes become elevated in most patients (70.59 %) but spontaneously decreased. DISCUSSION Our findings suggest that a 24 mg PER dose administered for 48 h may be more effective in managing RSE and SRSE compared to doses below 24 mg, potentially due to pharmacokinetic factors. CONCLUSION More robust data on PER in RSE and SRSE, including standardized dosing procedures and plasma level monitoring are needed. PER's potential benefits should be explored further, particularly in patients with RSE and SRSE.
Collapse
Affiliation(s)
- G Bruschi
- Unit of Neurology and Unit of Clinical Neurophysiology, Department of Neuroscience, University of Padua, Padua, Italy.
| | - L Pellegrino
- Unit of Neurology and Unit of Clinical Neurophysiology, Department of Neuroscience, University of Padua, Padua, Italy.
| | - A L Bisogno
- Unit of Neurology and Unit of Clinical Neurophysiology, Department of Neuroscience, University of Padua, Padua, Italy.
| | - F Ferreri
- Unit of Neurology and Unit of Clinical Neurophysiology, Department of Neuroscience, University of Padua, Padua, Italy; Department of Clinical Neurophysiology, Kuopio University Hospital, University of Eastern Finland, Kuopio, Finland.
| | - B Kassabian
- Unit of Neurology and Unit of Clinical Neurophysiology, Department of Neuroscience, University of Padua, Padua, Italy.
| | - D Seppi
- Unit of Neurology and Unit of Clinical Neurophysiology, Department of Neuroscience, University of Padua, Padua, Italy.
| | - S Favaretto
- Unit of Neurology and Unit of Clinical Neurophysiology, Department of Neuroscience, University of Padua, Padua, Italy.
| | - M Corbetta
- Unit of Neurology and Unit of Clinical Neurophysiology, Department of Neuroscience, University of Padua, Padua, Italy; Veneto Institute of Molecular Medicine (VIMM), Padua, Italy.
| | - F Dainese
- Unit of Neurology and Unit of Clinical Neurophysiology, Department of Neuroscience, University of Padua, Padua, Italy.
| |
Collapse
|
2
|
Cutillo G, Bonacchi R, Vabanesi M, Cecchetti G, Bellini A, Filippi M, Fanelli GF. Perampanel as an Add-On Therapy in Patients with Refractory Status Epilepticus and Postanoxic Encephalopathy: A Real-Life Single-Center Retrospective Cohort Study. Neurocrit Care 2024:10.1007/s12028-024-02019-w. [PMID: 38872031 DOI: 10.1007/s12028-024-02019-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 05/16/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Data on the efficacy of perampanel in refractory status epilepticus (RSE) and postanoxic encephalopathy (PAE) are limited; its use in such conditions is currently off-label. METHODS We conducted a retrospective cohort study of consecutive adult patients with RSE, including PAE, exhibiting electroencephalographic patterns indicative of status epilepticus who were treated at our center (January 2018 to December 2022) with assessment of clinical and electroencephalographic outcomes. RESULTS Thirty-six patients were included in the study, of whom 29 had nonanoxic RSE and 7 had PAE. Within the nonanoxic RSE subgroup, 45% (13 of 29; 95% confidence interval [CI] 27-63%) of study participants were responders, 34% (10 of 29; 95% CI 17-52%) were partial responders, and 21% (6 of 29; 95% CI 6-35%) were nonresponders. In the PAE subgroup (n = 7), no patients fully responded to perampanel; 43% (3 of 7; 95% CI 6-80%) were partial responders, and 57% (4 of 7; 95% CI 20-95%) were nonresponders. Responder and nonresponder study participants exhibited overlapping baseline characteristics. No significant differences in duration of hospitalization were observed between responders and nonresponders in both subgroups. Responders in the RSE subgroup had a median discharge modified Rankin Scale score of 3 (interquartile range 3-4), and nonresponders had a median discharge modified Rankin Scale score of 5 (interquartile range 5-6). CONCLUSIONS Despite limitations from the retrospective design and the small population size, this study suggests that perampanel use in nonanoxic RSE appears to yield promising results at moderate doses, including a tendency toward a better functional outcome at discharge, without significant adverse effects. However, in patients with PAE, the drug seems to show suboptimal performance. Perampanel appears to have promising efficacy as an add-on therapy in nonanoxic RSE. However, in patients with PAE, its efficacy seems to be lower. Further studies are warranted to confirm these observations.
Collapse
Affiliation(s)
- Gianni Cutillo
- Neurophysiology Service, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Milan, Italy
- Neurology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Via Olgettina, 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Raffaello Bonacchi
- Vita-Salute San Raffaele University, Milan, Italy
- Neuroradiology Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Milan, Italy
| | - Marco Vabanesi
- Neurology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Via Olgettina, 60, 20132, Milan, Italy
| | - Giordano Cecchetti
- Neurophysiology Service, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Milan, Italy
- Neurology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Via Olgettina, 60, 20132, Milan, Italy
| | - Anna Bellini
- Neurophysiology Service, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Milan, Italy
- Neurology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Via Olgettina, 60, 20132, Milan, Italy
| | - Massimo Filippi
- Neurophysiology Service, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Milan, Italy.
- Neurology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Via Olgettina, 60, 20132, Milan, Italy.
- Vita-Salute San Raffaele University, Milan, Italy.
- Neurorehabilitation Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Milan, Italy.
- Neuroimaging Research Unit, Division of Neuroscience, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Milan, Italy.
| | - Giovanna F Fanelli
- Neurophysiology Service, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Milan, Italy
- Neurology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Via Olgettina, 60, 20132, Milan, Italy
| |
Collapse
|
3
|
Almohaish S, Tesoro EP, Brophy GM. Status Epilepticus: An Update on Pharmacological Management. Semin Neurol 2024; 44:324-332. [PMID: 38580318 DOI: 10.1055/s-0044-1785503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
Status epilepticus (SE) is a neurological emergency that requires timely pharmacological therapy to cease seizure activity. The treatment approach varies based on the time and the treatment stage of SE. Benzodiazepines are considered the first-line therapy during the emergent treatment phase of SE. Antiseizure medicines such as phenytoin, valproic acid, and levetiracetam are recommended during the urgent treatment phase. These drugs appear to have a similar safety and efficacy profile, and individualized therapy should be chosen based on patient characteristics. Midazolam, propofol, pentobarbital, and ketamine are continuous intravenous infusions of anesthetic medications utilized in the refractory SE (RSE) period. The most efficacious pharmacotherapeutic treatments for RSE and superrefractory status epilepticus are not clearly defined.
Collapse
Affiliation(s)
- Sulaiman Almohaish
- Department of Pharmacy Practice, Clinical Pharmacy College, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Eljim P Tesoro
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Gretchen M Brophy
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
| |
Collapse
|
4
|
Damien C, Leitinger M, Kellinghaus C, Strzelczyk A, De Stefano P, Beier CP, Sutter R, Kämppi L, Strbian D, Taubøll E, Rosenow F, Helbok R, Rüegg S, Damian M, Trinka E, Gaspard N. Sustained effort network for treatment of status epilepticus/European academy of neurology registry on adult refractory status epilepticus (SENSE-II/AROUSE). BMC Neurol 2024; 24:19. [PMID: 38178048 PMCID: PMC10765797 DOI: 10.1186/s12883-023-03505-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 12/11/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Status Epilepticus (SE) is a common neurological emergency associated with a high rate of functional decline and mortality. Large randomized trials have addressed the early phases of treatment for convulsive SE. However, evidence regarding third-line anesthetic treatment and the treatment of nonconvulsive status epilepticus (NCSE) is scarce. One trial addressing management of refractory SE with deep general anesthesia was terminated early due to insufficient recruitment. Multicenter prospective registries, including the Sustained Effort Network for treatment of Status Epilepticus (SENSE), have shed some light on these questions, but many answers are still lacking, such as the influence exerted by distinct EEG patterns in NCSE on the outcome. We therefore initiated a new prospective multicenter observational registry to collect clinical and EEG data that combined may further help in clinical decision-making and defining SE. METHODS Sustained effort network for treatment of status epilepticus/European Academy of Neurology Registry on refractory Status Epilepticus (SENSE-II/AROUSE) is a prospective, multicenter registry for patients treated for SE. The primary objectives are to document patient and SE characteristics, treatment modalities, EEG, neuroimaging data, and outcome of consecutive adults admitted for SE treatment in each of the participating centers and to identify factors associated with outcome and refractoriness. To reach sufficient statistical power for multivariate analysis, a cohort size of 3000 patients is targeted. DISCUSSION The data collected for the registry will provide both valuable EEG data and information about specific treatment steps in different patient groups with SE. Eventually, the data will support clinical decision-making and may further guide the planning of clinical trials. Finally, it could help to redefine NCSE and its management. TRIAL REGISTRATION NCT number: NCT05839418.
Collapse
Affiliation(s)
- Charlotte Damien
- Department of Neurology, Hôpital Universitaire de Bruxelles, Hôpital Erasme, Brussels, Belgium
| | - Markus Leitinger
- Department of Neurology Neurointensive Care and Neurorehabilitation, Centre for Cognitive Neuroscience, Christian Doppler University Hospital, Paracelsus Medical University, European Reference Network EpiCARE, Salzburg, Austria
- Neuroscience Institute, Department of Neurology, Centre for Cognitive Neuroscience, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
| | | | - Adam Strzelczyk
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Pia De Stefano
- EEG & Epilepsy Unit, Department of Clinical Neurosciences, University Hospital of Geneva, Geneva, Switzerland
- Neuro-Intensive Care Unit, Department of Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - Christoph P Beier
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Raoul Sutter
- Department of Neurology, University Hospital Basel, Basel, Switzerland
- Intensive Care Units, University Hospital Basel, Basel, Switzerland
| | - Leena Kämppi
- Department of Neurology, Epilepsia Helsinki, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Daniel Strbian
- Department of Neurology, Epilepsia Helsinki, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Erik Taubøll
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Felix Rosenow
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Raimund Helbok
- Department of Neurology, Johannes Kepler University Linz, Linz, Austria
| | - Stephan Rüegg
- Department of Neurology, Epilepsia Helsinki, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Maxwell Damian
- Department of Critical Care, Essex Cardiothoracic Centre, Basildon, UK
| | - Eugen Trinka
- Department of Neurology Neurointensive Care and Neurorehabilitation, Centre for Cognitive Neuroscience, Christian Doppler University Hospital, Paracelsus Medical University, European Reference Network EpiCARE, Salzburg, Austria
- Neuroscience Institute, Department of Neurology, Centre for Cognitive Neuroscience, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
- Karl Landsteiner Institute of Neurorehabilitation and Space Neurology, Salzburg, Austria
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall en Tyrol, Austria
| | - Nicolas Gaspard
- Department of Neurology, Hôpital Universitaire de Bruxelles, Hôpital Erasme, Brussels, Belgium.
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA.
| |
Collapse
|
5
|
Nilo A, Vogrig A, Belluzzo M, Lettieri C, Verriello L, Valente M, Pauletto G. Efficacy of Perampanel in Refractory and Super-Refractory Status Epilepticus with Suspected Inflammatory Etiology: A Case Series. Pharmaceuticals (Basel) 2023; 17:28. [PMID: 38256862 PMCID: PMC10819860 DOI: 10.3390/ph17010028] [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: 09/28/2023] [Revised: 11/30/2023] [Accepted: 12/19/2023] [Indexed: 01/24/2024] Open
Abstract
(1) Background: Increasing evidence supports the anti-inflammatory and neuroprotective role of perampanel (PER), mediated by decreased expression of pro-inflammatory cytokines and by interference with apoptosis processes. Therefore, the use of PER to treat status epilepticus (SE) with suspected inflammatory etiology is appealing and deserves further investigation. (2) Methods: We retrospectively analyzed seven patients (five F, two M; median age: 62 years) with refractory and super-refractory SE due to a probable or defined inflammatory etiology and treated with PER. (3) Results: PER was administered as the third (4/7) or fourth drug (3/7), with a median loading dose of 32 mg/day (range: 16-36 mg/day) and a median maintenance dose of 10 mg/day (range: 4-12 mg/day). In five cases, SE was focal, while in two patients, it was generalized. SE was caused by systemic inflammation in three patients, while in the other four subjects, it was recognized to have an autoimmune etiology. SE resolution was observed after PER administration in all cases, particularly within 24 h in the majority of patients (4/7, 57.1%). (4) Conclusions: Our data support the efficacy of PER in treating SE when first- and second-line ASMs have failed and suggest a possible earlier use in SE cases that are due to inflammatory/autoimmune etiology.
Collapse
Affiliation(s)
- Annacarmen Nilo
- Clinical Neurology Unit, Department of Head, Neck and Neurosciences, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy; (A.V.); (C.L.); (M.V.)
- Department of Medicine, University of Udine, 33100 Udine, Italy
| | - Alberto Vogrig
- Clinical Neurology Unit, Department of Head, Neck and Neurosciences, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy; (A.V.); (C.L.); (M.V.)
- Department of Medicine, University of Udine, 33100 Udine, Italy
| | - Marco Belluzzo
- Neurology Unit, Department of Head, Neck and Neurosciences, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy; (M.B.); (L.V.); (G.P.)
| | - Christian Lettieri
- Clinical Neurology Unit, Department of Head, Neck and Neurosciences, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy; (A.V.); (C.L.); (M.V.)
| | - Lorenzo Verriello
- Neurology Unit, Department of Head, Neck and Neurosciences, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy; (M.B.); (L.V.); (G.P.)
| | - Mariarosaria Valente
- Clinical Neurology Unit, Department of Head, Neck and Neurosciences, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy; (A.V.); (C.L.); (M.V.)
- Department of Medicine, University of Udine, 33100 Udine, Italy
| | - Giada Pauletto
- Neurology Unit, Department of Head, Neck and Neurosciences, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy; (M.B.); (L.V.); (G.P.)
| |
Collapse
|
6
|
Fawcett J, Davis S, Manford M. Further advances in epilepsy. J Neurol 2023; 270:5655-5670. [PMID: 37458794 DOI: 10.1007/s00415-023-11860-6] [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: 05/31/2023] [Revised: 06/29/2023] [Accepted: 06/29/2023] [Indexed: 10/15/2023]
Abstract
In 2017, one of us reviewed advances in epilepsy (Manford in J Neurol 264:1811-1824, 2017). The current paper brings that review up to date and gives a slight change in emphasis. Once again, the story is of evolution rather than revolution. In recognition that most of our current medications act on neurotransmitters or ion channels, and not on the underlying changes in connectivity and pathways, they have been renamed as antiseizure (ASM) medications rather than antiepileptic drugs. Cenobamate is the one newly licensed medication for broader use in focal epilepsy but there have been a number of developments for specific disorders. We review new players and look forward to new developments in the light of evolving underlying science. We look at teratogenicity; old villains and new concerns in which clinicians play a vital role in explaining and balancing the risks. Medical treatment of status epilepticus, long without evidence, has benefitted from high-quality trials to inform practice; like buses, several arriving at once. Surgical treatment continues to be refined with improvements in the pre-surgical evaluation of patients, especially with new imaging techniques. Alternatives including stereotactic radiotherapy have received further focus and targets for palliative stimulation techniques have grown in number. Individuals' autonomy and quality of life continue to be the subject of research with refinement of what clinicians can do to help persons with epilepsy (PWE) achieve control. This includes seizure management but extends to broader considerations of human empowerment, needs and desires, which may be aided by emerging technologies such as seizure detection devices. The role of specialist nurses in improving that quality has been reinforced by specific endorsement from the International League against Epilepsy (ILAE).
Collapse
Affiliation(s)
- Joanna Fawcett
- Department of Neurology, Royal United Hospital, Bath, UK
| | - Sarah Davis
- Department of Neurology, Royal United Hospital, Bath, UK
| | - Mark Manford
- Department of Neurology, Royal United Hospital, Bath, UK.
| |
Collapse
|
7
|
Cornwall CD, Krøigård T, Kristensen JSS, Callesen HE, Beier CP. Outcomes and Treatment Approaches for Super-Refractory Status Epilepticus: A Systematic Review and Meta-Analysis. JAMA Neurol 2023; 80:2807605. [PMID: 37523161 PMCID: PMC10391362 DOI: 10.1001/jamaneurol.2023.2407] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/30/2023] [Indexed: 08/01/2023]
Abstract
Importance Super-refractory status epilepticus (SRSE) is defined as status epilepticus (SE) that continues or recurs 24 hours or more after the onset of anesthetic therapy or recurs on the reduction/withdrawal of anesthesia. Current clinical knowledge of the disease and optimal treatment approach is sparse. Objective To systematically assess clinical characteristics, causes, outcomes, prognostic factors, and treatment approaches for patients with SRSE. Design, Setting, and Participants In this systematic review and meta-analysis, all studies reporting adult patients (18 years or older) diagnosed with nonanoxic SRSE were considered for inclusion, irrespective of study design. The databases used were MEDLINE, Cochrane Library, EMBASE, and ClinicalTrials.org (database inception through May 5, 2022). Data extraction and synthesis The study complied with the PRISMA guidelines for reporting, data extraction, and data synthesis. Different tools were used to assess risk of bias. All available data were extracted and missing data were neither imputed nor completed by contacting the study authors. Main outcome and measures Successful treatment of SRSE, in-hospital mortality, and disability at discharge (estimated modified Rankin Scale). Results The study team identified a total of 95 articles and 30 conference abstracts reporting 1200 patients with nonanoxic SRSE (266 individual patients were available for meta-analysis). They had a mean SRSE duration of 36.3 days, mean age of 40.8 years, and equal sex distribution. Patients with SRSE had a distinct pattern of etiologies where acute cerebral events and unknown etiologies accounted for 41.6% and 22.3% of all etiologies, respectively. Reports of SRSE caused by, eg, alcohol, drugs, or tumors were rare. At discharge, only 26.8% had none to slight disability (none, 16 [8.4%]; nonsignificant and slight disability, 35 [18.4%]). In-hospital mortality was 24.1%. Mortality stabilized after long-term treatment (more than 28 days) but with increased rates of seizure cessation and moderate to severe disability. Established prognostic factors, such as age and etiology, were not associated with in-hospital mortality. Reported treatment with ketamine, phenobarbital, other barbiturates, vagus nerve stimulator, and ketogenic diet were not associated with outcome. Conclusion and Relevance Patients with SRSE are distinct due to their pattern of care (eg, long-term treatment to younger patients without negative prognostic factors and unknown/nonmalignant etiologies) and their natural course of SE. Very long-term treatment was associated with lower mortality and high odds of cessation of SRSE but increased risk of moderate to severe disability.
Collapse
Affiliation(s)
| | - Thomas Krøigård
- Department of Neurology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | | | - Christoph Patrick Beier
- Department of Neurology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- OPEN, Open Patient data Explorative Network, Odense University Hospital, Odense, Denmark
| |
Collapse
|
8
|
Perversi F, Costa C, Labate A, Lattanzi S, Liguori C, Maschio M, Meletti S, Nobili L, Operto FF, Romigi A, Russo E, Di Bonaventura C. The broad-spectrum activity of perampanel: state of the art and future perspective of AMPA antagonism beyond epilepsy. Front Neurol 2023; 14:1182304. [PMID: 37483446 PMCID: PMC10359664 DOI: 10.3389/fneur.2023.1182304] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/07/2023] [Indexed: 07/25/2023] Open
Abstract
Glutamate is the brain's main excitatory neurotransmitter. Glutamatergic neurons primarily compose basic neuronal networks, especially in the cortex. An imbalance of excitatory and inhibitory activities may result in epilepsy or other neurological and psychiatric conditions. Among glutamate receptors, AMPA receptors are the predominant mediator of glutamate-induced excitatory neurotransmission and dictate synaptic efficiency and plasticity by their numbers and/or properties. Therefore, they appear to be a major drug target for modulating several brain functions. Perampanel (PER) is a highly selective, noncompetitive AMPA antagonist approved in several countries worldwide for treating different types of seizures in various epileptic conditions. However, recent data show that PER can potentially address many other conditions within epilepsy and beyond. From this perspective, this review aims to examine the new preclinical and clinical studies-especially those produced from 2017 onwards-on AMPA antagonism and PER in conditions such as mesial temporal lobe epilepsy, idiopathic and genetic generalized epilepsy, brain tumor-related epilepsy, status epilepticus, rare epileptic syndromes, stroke, sleep, epilepsy-related migraine, cognitive impairment, autism, dementia, and other neurodegenerative diseases, as well as provide suggestions on future research agenda aimed at probing the possibility of treating these conditions with PER and/or other AMPA receptor antagonists.
Collapse
Affiliation(s)
| | - Cinzia Costa
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
- Neurological Clinic, S. Maria Della Misericordia Hospital, Perugia, Italy
| | - Angelo Labate
- Neurophysiopatology and Movement Disorders Clinic, University of Messina, Messina, Italy
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Claudio Liguori
- Department of Systems Medicine, University of Rome ‘Tor Vergata”, Rome, Italy
- Epilepsy Center, Neurology Unit, University Hospital “Tor Vergata”, Rome, Italy
| | - Marta Maschio
- Center for Tumor-Related Epilepsy, UOSD Neuro-Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Stefano Meletti
- Neurology Department, University Hospital of Modena, Modena, Italy
- Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio-Emilia, Modena, Italy
| | - Lino Nobili
- Child Neuropsychiatry Unit, IRCCS Istituto G. Gaslini, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Child and Maternal Health (DINOGMI), University of Genova, Genova, Italy
| | - Francesca Felicia Operto
- Child and Adolescent Neuropsychiatry Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
- Department of Science of Health, School of Medicine, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Andrea Romigi
- Sleep Medicine Center, Neurological Mediterranean Institute IRCCS Neuromed, Pozzilli, Italy
- Psychology Faculty, International Telematic University Uninettuno, Rome, Italy
| | - Emilio Russo
- Department of Science of Health, School of Medicine, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Carlo Di Bonaventura
- Epilepsy Unit, Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| |
Collapse
|
9
|
Meirinho S, Rodrigues M, Santos AO, Falcão A, Alves G. Nose-to-brain delivery of perampanel formulated in a self-microemulsifying drug delivery system improves anticonvulsant and anxiolytic activity in mice. Int J Pharm 2023:123145. [PMID: 37330157 DOI: 10.1016/j.ijpharm.2023.123145] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/05/2023] [Accepted: 06/12/2023] [Indexed: 06/19/2023]
Abstract
Perampanel (PER) is a potent third-generation antiepileptic drug only available for oral administration. Additionally, PER has shown potential in managing epilepsy comorbidities such as anxiety. Previously, we demonstrated that the intranasal (IN) administration of PER, loaded in a self-microemulsifying drug delivery system (SMEDDS), improved brain-targeting and exposure in mice. Herein, we investigated PER brain biodistribution, its anticonvulsant and anxiolytic effects, and its potential olfactory and neuromotor toxicity after IN administration to mice (1 mg/kg). PER showed a rostral-caudal brain biodistribution pattern when administered intranasally. At short times post-nasal dosing, high PER concentrations were found in olfactory bulbs (olfactory bulbs/plasma ratios of 1.266 ± 0.183 and 0.181 ± 0.027 after IN and intravenous administrations, respectively), suggesting that a fraction of the drug directly reaches brain through the olfactory pathway. In maximal electroshock seizure test, IN PER protected 60% of mice against seizure development, a substantially higher value than the 20% protected after receiving oral PER. . PER also demonstrated anxiolytic effects in open field and elevated plus maze tests. Buried food-seeking test showed no signs of olfactory toxicity. Neuromotor impairment was found in rotarod and open field tests at the times of PER maximum concentrations after IN and oral administrations. Nevertheless, neuromotor performance was improved after repeated administrations. Compared with IN vehicle, PER IN administration decreased brain levels of L-glutamate (0.91 ± 0.13 mg/mL vs 0.64 ± 0.12 mg/mL) and nitric oxide (100 ± 15.62% vs 56.62 ± 4.95%), without interfering in GABA levels. Altogether, these results suggest that the IN PER delivery through the developed SMEDDS can be a safe and promising alternative to oral treatment, which support the design of clinical studies to evaluate the IN PER delivery to treat epilepsy and neurological-related conditions as anxiety.
Collapse
Affiliation(s)
- Sara Meirinho
- CICS-UBI - Health Sciences Research Center, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal
| | - Márcio Rodrigues
- CICS-UBI - Health Sciences Research Center, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; CPIRN-UDI-IPG - Center for Potential and Innovation of Natural Resources, Research Unit for Inland Development, Polytechnic Institute of Guarda, Av. Dr. Francisco de Sá Carneiro, 6300-559 Guarda, Portugal
| | - Adriana O Santos
- CICS-UBI - Health Sciences Research Center, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal
| | - Amílcar Falcão
- Laboratory of Pharmacology, Faculty of Pharmacy, University of Coimbra, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal; CIBIT/ICNAS - Coimbra Institute for Biomedical Imaging and Translational Research, University of Coimbra, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal
| | - Gilberto Alves
- CICS-UBI - Health Sciences Research Center, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal.
| |
Collapse
|
10
|
Naylor DE. In the fast lane: Receptor trafficking during status epilepticus. Epilepsia Open 2023; 8 Suppl 1:S35-S65. [PMID: 36861477 PMCID: PMC10173858 DOI: 10.1002/epi4.12718] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 02/23/2023] [Indexed: 03/03/2023] Open
Abstract
Status epilepticus (SE) remains a significant cause of morbidity and mortality and often is refractory to standard first-line treatments. A rapid loss of synaptic inhibition and development of pharmacoresistance to benzodiazepines (BZDs) occurs early during SE, while NMDA and AMPA receptor antagonists remain effective treatments after BZDs have failed. Multimodal and subunit-selective receptor trafficking within minutes to an hour of SE involves GABA-A, NMDA, and AMPA receptors and contributes to shifts in the number and subunit composition of surface receptors with differential impacts on the physiology, pharmacology, and strength of GABAergic and glutamatergic currents at synaptic and extrasynaptic sites. During the first hour of SE, synaptic GABA-A receptors containing γ2 subunits move to the cell interior while extrasynaptic GABA-A receptors with δ subunits are preserved. Conversely, NMDA receptors containing N2B subunits are increased at synaptic and extrasynaptic sites, and homomeric GluA1 ("GluA2-lacking") calcium permeant AMPA receptor surface expression also is increased. Molecular mechanisms, largely driven by NMDA receptor or calcium permeant AMPA receptor activation early during circuit hyperactivity, regulate subunit-specific interactions with proteins involved with synaptic scaffolding, adaptin-AP2/clathrin-dependent endocytosis, endoplasmic reticulum (ER) retention, and endosomal recycling. Reviewed here is how SE-induced shifts in receptor subunit composition and surface representation increase the excitatory to inhibitory imbalance that sustains seizures and fuels excitotoxicity contributing to chronic sequela such as "spontaneous recurrent seizures" (SRS). A role for early multimodal therapy is suggested both for treatment of SE and for prevention of long-term comorbidities.
Collapse
Affiliation(s)
- David E Naylor
- VA Greater Los Angeles Healthcare System, Department of Neurology, David Geffen School of Medicine at UCLA, and The Lundquist Institute at Harbor-UCLA Medical Center, Los Angeles, California, USA
| |
Collapse
|
11
|
Kellinghaus C. Making SENSE of what we do - How to bring evidence to clinical practice. Epilepsy Behav 2023; 140:109103. [PMID: 36739635 DOI: 10.1016/j.yebeh.2023.109103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 01/16/2023] [Indexed: 02/05/2023]
Abstract
Status epilepticus is a frequent neurological emergency. Several audits and registries have enhanced our knowledge regarding patient demography, etiology, treatment, and outcome. Several large registries have also contributed significantly to current treatment guidelines that emphasize the importance of instant and effective treatment onset. Large registries also document that deviation from these treatment guidelines is not the exception but the rule. Therefore, careful analysis of the treatment pathways as well as balanced intervention efforts are necessary to overcome the gap between knowledge and action. This paper was presented at the 8th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures held in September 2022.
Collapse
Affiliation(s)
- Christoph Kellinghaus
- Department of Neurology, Klinikum Osnabrück, Am Finkenhügel 1, 49076 Osnabrück, Germany.
| |
Collapse
|
12
|
Huang TH, Lai MC, Chen YS, Huang CW. The Roles of Glutamate Receptors and Their Antagonists in Status Epilepticus, Refractory Status Epilepticus, and Super-Refractory Status Epilepticus. Biomedicines 2023; 11:biomedicines11030686. [PMID: 36979664 PMCID: PMC10045490 DOI: 10.3390/biomedicines11030686] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/18/2023] [Accepted: 02/21/2023] [Indexed: 03/30/2023] Open
Abstract
Status epilepticus (SE) is a neurological emergency with a high mortality rate. When compared to chronic epilepsy, it is distinguished by the durability of seizures and frequent resistance to benzodiazepine (BZD). The Receptor Trafficking Hypothesis, which suggests that the downregulation of γ-Aminobutyric acid type A (GABAA) receptors, and upregulation of N-methyl-D-aspartate (NMDA) and α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors play major roles in the establishment of SE is the most widely accepted hypothesis underlying BZD resistance. NMDA and AMPA are ionotropic glutamate receptor families that have important excitatory roles in the central nervous system (CNS). They are both essential in maintaining the normal function of the brain and are involved in a variety of neuropsychiatric diseases, including epilepsy. Based on animal and human studies, antagonists of NMDA and AMPA receptors have a significant impact in ending SE; albeit most of them are not yet approved to be in clinically therapeutic guidelines, due to their psychomimetic adverse effects. Although there is still a dearth of randomized, prospective research, NMDA antagonists such as ketamine, magnesium sulfate, and the AMPA antagonist, perampanel, are regarded to be reasonable optional adjuvant therapies in controlling SE, refractory SE (RSE) or super-refractory SE (SRSE), though there are still a lack of randomized, prospective studies. This review seeks to summarize and update knowledge on the SE development hypothesis, as well as clinical trials using NMDA and AMPA antagonists in animal and human studies of SE investigations.
Collapse
Affiliation(s)
- Tzu-Hsin Huang
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70142, Taiwan
- Zhengxin Neurology & Rehabilitation Center, Tainan 70459, Taiwan
| | - Ming-Chi Lai
- Department of Pediatrics, Chi-Mei Medical Center, Tainan 71004, Taiwan
| | - Yu-Shiue Chen
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70142, Taiwan
| | - Chin-Wei Huang
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70142, Taiwan
| |
Collapse
|
13
|
Reindl C, Madžar D, Hamer HM. [Status epilepticus-Detection and treatment in the intensive care unit]. DER NERVENARZT 2023; 94:120-128. [PMID: 36534176 DOI: 10.1007/s00115-022-01418-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/08/2022] [Indexed: 12/24/2022]
Abstract
Status epilepticus is characterized by persistent or repetitive seizures which, without successful treatment, can lead to neuronal damage, neurological deficits and death of the patient.While status epilepticus with motor symptoms can usually be clinically diagnosed, nonconvulsive status epilepticus is often clinically overlooked due to its ambiguous semiology, so that electroencephalography (EEG) recording is necessary. The treatment of status epilepticus is performed in four treatment steps, whereby a difficult to treat status epilepticus is present from the third step at the latest and intensive medical care of the patient is necessary. Timely initiation of treatment and sufficient dosage of anticonvulsive medication are decisive for the success of treatment. There is little evidence for the "late" stages of treatment. Intensive medical measures pose the risk of complications that worsen the prognosis. Especially in nonconvulsive status epilepticus, the use of anesthetics must be weighed against possible complications of mechanical ventilation.
Collapse
Affiliation(s)
- Caroline Reindl
- Neurologische Klinik, Epilepsiezentrum, Universitätsklinikum Erlangen, Schwabachanlage 6, 91054, Erlangen, Deutschland.
| | - Dominik Madžar
- Neurologische Klinik, Universitätsklinikum Erlangen, Schwabachanlage 6, 91054, Erlangen, Deutschland
| | - Hajo M Hamer
- Neurologische Klinik, Epilepsiezentrum, Universitätsklinikum Erlangen, Schwabachanlage 6, 91054, Erlangen, Deutschland
| |
Collapse
|
14
|
Löscher W, Trinka E. The potential of intravenous topiramate for the treatment of status epilepticus. Epilepsy Behav 2023; 138:109032. [PMID: 36528009 DOI: 10.1016/j.yebeh.2022.109032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/28/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022]
Abstract
There is considerable clinical evidence that topiramate (TPM) has a high potential in the treatment of refractory and super-refractory status epilepticus (RSE, SRSE). Because TPM is only approved for oral administration, it is applied as suspension via a nasogastric tube for SE treatment. However, this route of administration is impractical in an emergency setting and leads to variable absorption with unpredictable plasma levels and time to peak concentration. Thus, the development of an intravenous (i.v.) solution for TPM is highly desirable. Here we present data on two parenteral formulations of TPM that are currently being developed. One of these solutions is using sulfobutylether-β-cyclodextrin (SBE-β-CD; Captisol®) as an excipient. A 1% solution of TPM in 10% Captisol® has been reported to be well tolerated in safety studies in healthy volunteers and patients with epilepsy or migraine, but efficacy data are not available. The other solution uses the FDA- and EMA-approved excipient amino sugar meglumine. Meglumine is much more effective to dissolve TPM in water than Captisol®. A 1% solution of TPM can be achieved with 0.5-1% of meglumine. While the use of Captisol®-containing solutions is restricted in children and patients with renal impairment, such restrictions do not apply to meglumine. Recently, first-in-human data were reported for a meglumine-based solution of TPM, indicating safety and efficacy when used as a replacement for oral administration in a woman with epilepsy. Based on the multiple mechanisms of action of TPM that directly target the molecular neuronal alterations that are thought to underlie the loss of efficacy of benzodiazepines and other anti-seizure medications during prolonged SE and its rapid brain penetration after i.v. administration, we suggest that parenteral (i.v.) TPM is ideally suited for the treatment of RSE and SRSE. This paper was presented at the 8th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures held in September 2022.
Collapse
Affiliation(s)
- Wolfgang Löscher
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, 30559 Hannover, Germany; Center for Systems Neuroscience, 30559 Hannover, Germany.
| | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria; Center for Cognitive Neuroscience, Salzburg, Austria
| |
Collapse
|
15
|
Wang X, Yang F, Chen B, Jiang W. Non‐convulsive seizures and non‐convulsive status epilepticus in neuro‐intensive care unit. Acta Neurol Scand 2022; 146:752-760. [DOI: 10.1111/ane.13718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 10/07/2022] [Accepted: 10/11/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Xuan Wang
- Department of Neurology, Xijing Hospital Fourth Military Medical University Xi'an China
| | - Fang Yang
- Department of Neurology, Xijing Hospital Fourth Military Medical University Xi'an China
| | - Beibei Chen
- Department of Neurology, Xijing Hospital Fourth Military Medical University Xi'an China
| | - Wen Jiang
- Department of Neurology, Xijing Hospital Fourth Military Medical University Xi'an China
| |
Collapse
|
16
|
Meirinho S, Rodrigues M, Ferreira CL, Oliveira RC, Fortuna A, Santos AO, Falcão A, Alves G. Intranasal delivery of lipid-based nanosystems as a promising approach for brain targeting of the new-generation antiepileptic drug perampanel. Int J Pharm 2022; 622:121853. [PMID: 35623483 DOI: 10.1016/j.ijpharm.2022.121853] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 05/19/2022] [Indexed: 01/29/2023]
Abstract
Perampanel (PER), a new-generation antiepileptic drug effective against different types of seizures, has already demonstrated a potential in status epilepticus therapy. Considering the growing interest of intranasal (IN) administration for nose-to-brain delivery, PER could be envisioned as a good candidate for this route, especially if formulated in a lipid-based nanosystem. With that purpose, a hydrophobic formulation (FO1.2) and a self-microemulsifying drug delivery system (SMEDDS) (FH5) loaded with PER were developed and characterized. Following PER IN administration (1 mg/kg) to mice, its pharmacokinetics was characterized and compared with intravenous and oral routes. Histopathological toxicity was also examined after a 7-day repeated dose study. FH5 homogeneously formed nanodroplets upon dispersion (20.07 ± 0.03 nm), showing a sustained in vitro PER release profile up to 4 h. By IN route, PER brain delivery was more extensive with FH5 (Cmax and AUC of 52.32 ng/g and 190.35 ng.h/g for FO1.2; 93.87 ng/g and 257.75 ng.h/g for FH5). Maximum brain concentration and total brain exposure were higher than those obtained after oral dosage, with maximum PER concentrations reached significantly faster than post-oral administration (15 min vs 2 h). An improvement in PER plasmatic concentration was also obtained, demonstrated by high relative bioavailability values (134.1% for FH5 and 107.8% for FO1.2). PER absolute plasma bioavailability after IN delivery was 55.5% for FH5 and 44.6% for FO1.2, ensuring a somewhat improved targeting of PER to the brain by the IN route compared to the IV route. No signs of toxicity were found by histopathologic evaluation. Results suggest that IN administration of PER might be a feasible and safe approach for acute and chronic epilepsy management, especially using delivery systems as SMEDDS.
Collapse
Affiliation(s)
- Sara Meirinho
- CICS-UBI - Health Sciences Research Center, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal
| | - Márcio Rodrigues
- CICS-UBI - Health Sciences Research Center, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; CPIRN-UDI-IPG-Center for Potential and Innovation of Natural Resources, Research Unit for Inland Development, Polythecnic of Guarda, 6300-559 Guarda, Portugal
| | - Catarina L Ferreira
- CICS-UBI - Health Sciences Research Center, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal
| | - Rui Caetano Oliveira
- Pathology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Biophysics Institute, Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR) Area of Environment Genetics and Oncobiology (CIMAGO), Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal
| | - Ana Fortuna
- Laboratory of Pharmacology, Faculty of Pharmacy, University of Coimbra, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal; CIBIT/ICNAS - Coimbra Institute for Biomedical Imaging and Translational Research, University of Coimbra, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal
| | - Adriana O Santos
- CICS-UBI - Health Sciences Research Center, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal
| | - Amílcar Falcão
- Laboratory of Pharmacology, Faculty of Pharmacy, University of Coimbra, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal; CIBIT/ICNAS - Coimbra Institute for Biomedical Imaging and Translational Research, University of Coimbra, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal
| | - Gilberto Alves
- CICS-UBI - Health Sciences Research Center, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal.
| |
Collapse
|
17
|
Perez DQ, Espiritu AI, Jamora RDG. Perampanel in achieving status epilepticus cessation: A systematic review. Epilepsy Behav 2022; 128:108583. [PMID: 35151187 DOI: 10.1016/j.yebeh.2022.108583] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/18/2022] [Accepted: 01/18/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Status epilepticus (SE) is a neurological emergency necessitating rapid seizure control to prevent long-term consequences. Perampanel (PER) is a novel selective, noncompetitive alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic (AMPA) receptor antagonist that demonstrated efficacy and safety in lithium-pilocarpine models of SE; however, data in humans are limited. This systematic review was performed to assess the efficacy and safety of PER in patients with SE, RSE, and SRSE. METHODS We searched MEDLINE (accessed through PubMed), Embase, Scopus, Cochrane Library, and ClinicalTrials.gov from inception until May 30, 2021 to identify all human studies on PER for the treatment of SE of any type and etiology. An additional search was performed on DANS Easy Archive, in which OpenGrey data were stored, from inception until January 10, 2022 and conference proceedings by the International League Against Epilepsy from 2011 onward. The GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to assess the overall certainty of the body of evidence. RESULTS Twenty-one studies (7 case reports, 9 case series, and 5 retrospective cohort studies) were included with a total of 369 cases of SE in 368 patients aged 11 months to 99 years, of which 56.2% were female. Seizures of the majority were refractory (n = 220), super refractory SE (n = 70), or either (n = 81) with prominent motor symptoms (n = 284) and are associated with a structural etiology (n = 218). The number of antiseizure medications and/or anesthetics used prior to PER ranged from 1 to 13. PER was administered in 324 cases and was initiated at a dose of 2-36 mg between 30 min to 59 days from SE onset. SE cessation ranged from 1 h to 4 weeks from PER initiation. A total of 119 cases (36.6%) were considered PER responders. According to the GRADE approach, there is very low certainty of evidence for all outcomes. CONCLUSIONS The real-world data of PER as a possible therapeutic option in SE of any type are increasing. However, there is very low certainty of evidence for its use and this requires further clinical studies to establish the appropriate timing, dosing, and titration that are efficacious and safe for SE cessation.
Collapse
Affiliation(s)
- Dominique Q Perez
- Department of Clinical Neurosciences, University of the East Ramon Magsaysay Memorial Medical Center Inc., Quezon City, Philippines; Section of Neurology, Department of Internal Medicine, Cardinal Santos Medical Center, San Juan City, Philippines
| | - Adrian I Espiritu
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines, Manila, Manila, Philippines; Department of Clinical Epidemiology, College of Medicine, University of the Philippines, Manila, Manila, Philippines; Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Roland Dominic G Jamora
- Section of Neurology, Department of Internal Medicine, Cardinal Santos Medical Center, San Juan City, Philippines; Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines, Manila, Manila, Philippines; Institute for Neurosciences, St. Luke's Medical Center, Global City, Philippines.
| |
Collapse
|
18
|
Wechsler RT, Wheless J, Zafar M, Huesmann GR, Lancman M, Segal E, Chez M, Aboumatar S, Patten A, Salah A, Malhotra M. PROVE: retrospective, non-interventional, Phase IV study of perampanel in real-world clinical care of patients with epilepsy. Epilepsia Open 2021; 7:293-305. [PMID: 34942053 PMCID: PMC9159249 DOI: 10.1002/epi4.12575] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 11/22/2021] [Accepted: 11/29/2021] [Indexed: 11/11/2022] Open
Abstract
Objective To assess retention, dosing, efficacy, and safety of perampanel in a large cohort of patients with epilepsy during routine clinical care. Methods PROVE was a retrospective, non‐interventional Phase IV study (NCT03208660). Data were obtained retrospectively from the medical records of patients in the United States initiating perampanel after January 1, 2014, according to treating clinicians' recommendation. Retention rate was the primary efficacy endpoint. Secondary efficacy endpoints included median percent changes in seizure frequency per 28 days from baseline, seizure‐freedom rate, and overall investigator impression of seizure effect. Safety endpoints included incidence of treatment‐emergent adverse events (TEAEs). Efficacy and safety were also assessed according to baseline use of enzyme‐inducing antiseizure medications (EIASMs). Results Overall, 1703 patients were enrolled and included in the Safety Analysis Set (SAS; ≥1 baseline EIASMs, n = 358 [21.0%]; no baseline EIASMs, n = 1345 [79.0%]). Mean (standard deviation [SD]) cumulative duration of exposure to perampanel was 17.4 (15.7) months; mean (SD) daily perampanel dose was 5.6 (2.7) mg. The most frequent perampanel titration intervals were weekly (23.4%) and every 2 weeks (24.7%). Across the SAS, 24‐month retention rate was 48.1% (n = 501/1042). Based on overall investigator impression at the end of treatment, 51.9%, 35.8%, and 12.3% of patients in the SAS experienced improvement, no change, or worsening of seizures, respectively. TEAEs occurred in 704 (41.3%) patients; 79 (4.6%) had serious TEAEs. The most common TEAE was dizziness (7.3%). There was some variation in efficacy according to EIASM use, while retention rates and safety were generally consistent. Significance In this final analysis of >1700 patients with epilepsy receiving perampanel in routine clinical care, favorable retention and sustained efficacy were demonstrated for ≥12 months.
Collapse
Affiliation(s)
| | - James Wheless
- University of Tennessee, Le Bonheur Children's Hospital, Memphis, TN, USA
| | | | | | - Marcelo Lancman
- Northeast Regional Epilepsy Group, Hackensack University Medical Center, Hackensack Meridian School of Medicine, Hackensack, NJ, USA
| | - Eric Segal
- Northeast Regional Epilepsy Group, Hackensack University Medical Center, Hackensack Meridian School of Medicine, Hackensack, NJ, USA
| | - Michael Chez
- Sutter Neuroscience Institute, Roseville, CA, USA
| | | | - Anna Patten
- Eisai Europe Ltd, Hatfield, Hertfordshire, UK
| | | | | |
Collapse
|
19
|
Epidemiology, management and outcome of status epilepticus in adults: single-center Italian survey. Neurol Sci 2021; 43:2003-2013. [PMID: 34490535 DOI: 10.1007/s10072-021-05572-w] [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: 05/22/2021] [Accepted: 08/17/2021] [Indexed: 10/20/2022]
Abstract
The official variations of status epilepticus (SE) International League Against Epilepsy (ILAE, 2015) diagnostic criteria and the non-convulsive SE (NCSE) Salzburg Consensus Criteria (2013), impose the collection of updated population-based epidemiological Italian data. In this study, we aimed at evaluating (a) the frequency of SE in our hospital adopting the new ILAE 2015 SE diagnostic criteria and NCSE Salzburg Consensus Criteria, (b) the frequency of adherence to current treatment guidelines for SE and their relationship with patients' outcome, and (c) reliability of standardized prognostic scales (Status Epilepticus Severity Score-STESS-and modified STESS) for short-term outcome prediction in the setting of the newest diagnostic criteria for SE and NCSE. Detailed clinical and electrophysiological data collected in a 1-year retrospective hospital-based single-center survey on SE at Parma Hospital, Northern Italy are provided. Non-adherence to current treatment guidelines was recorded in around 50% cases, but no relation to outcome was appreciated. Mortality in our cohort increased from 30 to 50% when follow-up was extended to 30 days. STESS score was strongly correlated with short-term mortality risk (OR 18.9, 2.2-163.5, CI), and we confirm its role as easy-to-use tool for outcome evaluation also when the new ILAE diagnostic SE criteria are applied.
Collapse
|
20
|
PERMIT study: a global pooled analysis study of the effectiveness and tolerability of perampanel in routine clinical practice. J Neurol 2021; 269:1957-1977. [PMID: 34427754 PMCID: PMC8940799 DOI: 10.1007/s00415-021-10751-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/03/2021] [Accepted: 08/06/2021] [Indexed: 12/22/2022]
Abstract
The PERaMpanel pooled analysIs of effecTiveness and tolerability (PERMIT) study was a pooled analysis of data from 44 real-world studies from 17 countries, in which people with epilepsy (PWE; focal and generalized) were treated with perampanel (PER). Retention and effectiveness were assessed after 3, 6, and 12 months, and at the last visit (last observation carried forward). Effectiveness assessments included 50% responder rate (≥ 50% reduction in seizure frequency from baseline) and seizure freedom rate (no seizures since at least the prior visit); in PWE with status epilepticus, response was defined as seizures under control. Safety and tolerability were assessed by evaluating adverse events (AEs) and discontinuation due to AEs. The Full Analysis Set included 5193 PWE. Retention, effectiveness and safety/tolerability were assessed in 4721, 4392 and 4617, respectively. Retention on PER treatment at 3, 6, and 12 months was 90.5%, 79.8%, and 64.2%, respectively. Mean retention time on PER treatment was 10.8 months. The 50% responder rate was 58.3% at 12 months and 50.0% at the last visit, and the corresponding seizure freedom rates were 23.2% and 20.5%, respectively; 52.7% of PWE with status epilepticus responded to PER treatment. Overall, 49.9% of PWE reported AEs and the most frequently reported AEs (≥ 5% of PWE) were dizziness/vertigo (15.2%), somnolence (10.6%), irritability (8.4%), and behavioral disorders (5.4%). At 12 months, 17.6% of PWEs had discontinued due to AEs. PERMIT demonstrated that PER is effective and generally well tolerated when used to treat people with focal and/or generalized epilepsy in everyday clinical practice.
Collapse
|
21
|
Kirmani BF, Au K, Ayari L, John M, Shetty P, Delorenzo RJ. Super-Refractory Status Epilepticus: Prognosis and Recent Advances in Management. Aging Dis 2021; 12:1097-1119. [PMID: 34221552 PMCID: PMC8219503 DOI: 10.14336/ad.2021.0302] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/02/2021] [Indexed: 12/12/2022] Open
Abstract
Super-refractory status epilepticus (SRSE) is a life-threatening neurological emergency with high morbidity and mortality. It is defined as “status epilepticus (SE) that continues or recurs 24 hours or more after the onset of anesthesia, including those cases in which SE recurs on the reduction or withdrawal of anesthesia.” This condition is resistant to normal protocols used in the treatment of status epilepticus and exposes patients to increased risks of neuronal death, neuronal injury, and disruption of neuronal networks if not treated in a timely manner. It is mainly seen in patients with severe acute onset brain injury or presentation of new-onset refractory status epilepticus (NORSE). The mortality, neurological deficits, and functional impairments are significant depending on the duration of status epilepticus and the resultant brain damage. Research is underway to find the cure for this devastating neurological condition. In this review, we will discuss the wide range of therapies used in the management of SRSE, provide suggestions regarding its treatment, and comment on future directions. The therapies evaluated include traditional and alternative anesthetic agents with antiepileptic agents. The other emerging therapies include hypothermia, steroids, immunosuppressive agents, electrical and magnetic stimulation therapies, emergent respective epilepsy surgery, the ketogenic diet, pyridoxine infusion, cerebrospinal fluid drainage, and magnesium infusion. To date, there is a lack of robust published data regarding the safety and effectiveness of various therapies, and there continues to be a need for large randomized multicenter trials comparing newer therapies to treat this refractory condition.
Collapse
Affiliation(s)
- Batool F Kirmani
- 1Texas A&M University College of Medicine, College Station, TX, USA.,3Epilepsy and Functional Neurosurgery Program, Department of Neurology, CHI St. Joseph Health, Bryan, TX, USA
| | - Katherine Au
- 2George Washington University, School of Medicine & Health Sciences, Washington DC, USA
| | - Lena Ayari
- 1Texas A&M University College of Medicine, College Station, TX, USA
| | - Marita John
- 1Texas A&M University College of Medicine, College Station, TX, USA
| | - Padmashri Shetty
- 4M. S. Ramaiah Medical College, M. S. Ramaiah Nagar, Bengaluru, Karnataka, India
| | - Robert J Delorenzo
- 5Department of Neurology, Virginia Commonwealth University School of Medicine, Richmond, VA
| |
Collapse
|
22
|
Lattanzi S, Cagnetti C, Foschi N, Ciuffini R, Osanni E, Chiesa V, Dainese F, Dono F, Canevini MP, Evangelista G, Paladin F, Bartolini E, Ranzato F, Nilo A, Pauletto G, Marino D, Rosati E, Bonanni P, Marrelli A. Adjunctive Perampanel in Older Patients With Epilepsy: A Multicenter Study of Clinical Practice. Drugs Aging 2021; 38:603-610. [PMID: 34075567 PMCID: PMC8266697 DOI: 10.1007/s40266-021-00865-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2021] [Indexed: 11/26/2022]
Abstract
Background Clinical data regarding use of newer antiseizure medications (ASMs) in an older population are limited. In randomized-controlled, placebo-controlled trials, older patients are under-represented, and protocols deviate markedly from routine clinical practice, limiting the external validity of results. Studies performed in a naturalistic setting are a useful complement to characterize the drug profile. Perampanel is a third-generation ASM and the first and only non-competitive alfa-amino-3-hydroxyl-5-methyl-4-isoxazole-propionate receptor antagonist. Objective The aim of this study was to assess the effectiveness and tolerability of adjunctive perampanel over a 1‐year period in a population of older patients with epilepsy treated in a real-world setting. Methods Older (≥ 65 years of age) patients prescribed add-on perampanel at 12 Italian epilepsy centers were retrospectively identified. Seizure occurrence, adverse events (AEs), and drug withdrawal were analyzed. Effectiveness outcomes included the rates of seizure response (≥ 50% reduction in baseline monthly seizure frequency), seizure freedom, and treatment discontinuation. Safety and tolerability outcomes were the rate of treatment discontinuation due to AEs and the incidence of AEs. Results A total of 92 patients with a median age of 69 (range 65–88) years were included. The median daily dose of perampanel at 12 months was 6 mg (interquartile range 4–6 mg). At 12 months, 53 (57.6%) patients were seizure responders, and 22 (23.9%) patients were seizure free. Twenty (21.7%) patients discontinued perampanel; the reasons for treatment withdrawal were insufficient efficacy (n = 6/20; 30.0%), AEs (n = 12/20; 60.0%), and a combination of both (n = 2/20; 10%). The most common AEs included irritability (8.7%), somnolence (4.3%), and dizziness/vertigo (4.3%). The rate of behavioral and psychiatric AEs was higher in patients with history of psychiatric comorbidities (p = 0.044). There were no differences in the occurrence of behavioral and psychiatric AEs according to the concomitant use of levetiracetam (p = 0.776) and history of cognitive decline (p = 0.332). Conclusions Adjunctive perampanel was associated with improvement in seizure control and good tolerability in a real-life setting and can represent a viable therapeutic option in older patients with epilepsy.
Collapse
Affiliation(s)
- Simona Lattanzi
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Via Conca 71, 60020, Ancona, Italy.
| | - Claudia Cagnetti
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Via Conca 71, 60020, Ancona, Italy
| | - Nicoletta Foschi
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Via Conca 71, 60020, Ancona, Italy
| | - Roberta Ciuffini
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Elisa Osanni
- Epilepsy and Psychopathology Unit, IRCCS Medea, Conegliano, Treviso, Italy
| | | | | | - Fedele Dono
- Department of Neuroscience, Imaging and Clinical Science, "G. D'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Maria Paola Canevini
- Epilepsy Center, San Paolo Hospital, Milan, Italy
- Department of Health Sciences, Università degli Studi, Milan, Italy
| | - Giacomo Evangelista
- Department of Neuroscience, Imaging and Clinical Science, "G. D'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | | | | | | | - Annacarmen Nilo
- Clinical Neurology Unit, Department of Neurosciences, S. Maria della Misericordia University Hospital, ASUFC, Udine, Italy
| | - Giada Pauletto
- Neurology Unit, Department of Neurosciences, S. Maria della Misericordia University Hospital, ASUFC, Udine, Italy
| | - Daniela Marino
- Neurology Unit, Department of Cardiac, Thoracic, Neurological and Vascular Sciences, San Donato Hospital, Arezzo, Italy
| | - Eleonora Rosati
- Neurology Unit 2, Neuromuscular and Sense Organs Department, Careggi University Hospital, Florence, Italy
| | - Paolo Bonanni
- Epilepsy and Psychopathology Unit, IRCCS Medea, Conegliano, Treviso, Italy
| | - Alfonso Marrelli
- Neurophysiopathology Unit, Epilepsy Center, San Salvatore Hospital, L'Aquila, Italy
| |
Collapse
|
23
|
Real-world impact of antiepileptic drug combinations with versus without perampanel on healthcare resource utilization in patients with epilepsy in the United States. Epilepsy Behav 2021; 118:107927. [PMID: 33812233 DOI: 10.1016/j.yebeh.2021.107927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 03/02/2021] [Accepted: 03/06/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Combination regimens of antiepileptic drugs (AEDs) with various mechanisms of action (MOA) are commonly used in patients with refractory epilepsy. However, outcomes related to combination AEDs with novel MOA, such as perampanel (PER), are not well described. This study compared healthcare resource utilization (HRU) among recipients of PER-based combinations versus recipients of other non-PER-based combinations. METHODS This retrospective study used claims data from the Symphony Health's IDV® (Integrated Dataverse) database (August 2012 to July 2018). Patients were aged ≥12 years with epilepsy or non-febrile convulsions, were treated with AED combinations, and had ≥12 and ≥6 months pre- and post-index date, respectively (date of initiation of the second AED in the combination). AEDs were categorized based on MOA: selective non-competitive antagonist of AMPA receptors (i.e., PER), sodium channel blocker (SC), synaptic vesicle protein 2A binding (SV2), and gamma-aminobutyric acid analog (G). Patients were then classified into MOA-based cohorts: PER + SC, PER + SV2, PER + G, SC + SC, SC + SV2, SC + G, SV2 + G, and G + G. HRU outcomes were evaluated during follow-up and compared between PER-based cohorts and non-PER-based cohorts. RESULTS On average, patients in the PER + SC (N = 3,592), PER + SV2 (N = 2,200), and PER + G (N = 1,313) cohorts were younger and had a lower Quan-Charlson comorbidity index than those in non-PER-based cohorts. PER + SC and PER + SV2 users had significantly fewer all-cause hospitalizations than non-PER-based users (adjusted RR range: 0.66-0.89, all P < 0.05), while PER + G recipients had fewer all-cause hospitalizations than recipients of SV2 + G and G + G (adjusted RR range: 0.92-0.94). Similar trends were observed for epilepsy-related hospitalizations. Across all comparisons, PER-based combinations were associated with significantly lower rates of all-cause clinic/office/outpatient visits relative to non-PER-based combinations (adjusted RR range: 0.69-0.86, all P < 0.05). SIGNIFICANCE Results showed that patients treated with PER-based combinations had fewer all-cause and epilepsy-related hospitalizations, and fewer all-cause clinic/office/outpatient visits compared with patients treated with most other non-PER-based combinations.
Collapse
|
24
|
Pharmacotherapy for Nonconvulsive Seizures and Nonconvulsive Status Epilepticus. Drugs 2021; 81:749-770. [PMID: 33830480 DOI: 10.1007/s40265-021-01502-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2021] [Indexed: 12/22/2022]
Abstract
Most seizures in critically ill patients are nonconvulsive. A significant number of neurological and medical conditions can be complicated by nonconvulsive seizures (NCSs) and nonconvulsive status epilepticus (NCSE), with brain infections, hemorrhages, global hypoxia, sepsis, and recent neurosurgery being the most prominent etiologies. Prolonged NCSs and NCSE can lead to adverse neurological outcomes. Early recognition requires a high degree of suspicion and rapid and appropriate duration of continuous electroencephalogram (cEEG) monitoring. Although high quality research evaluating treatment with antiseizure medications and long-term outcome is still lacking, it is probable that expeditious pharmacological management of NCSs and NCSE may prevent refractoriness and further neurological injury. There is limited evidence on pharmacotherapy for NCSs and NCSE, although a few clinical trials encompassing both convulsive and NCSE have demonstrated similar efficacy of different intravenous (IV) antiseizure medications (ASMs), including levetiracetam, valproate, lacosamide and fosphenytoin. The choice of specific ASMs lies on tolerability and safety since critically ill patients frequently have impaired renal and/or hepatic function as well as hematological/hemodynamic lability. Treatment frequently requires more than one ASM and occasionally escalation to IV anesthetic drugs. When multiple ASMs are required, combining different mechanisms of action should be considered. There are several enteral ASMs that could be used when IV ASM options have been exhausted. Refractory NCSE is not uncommon, and its treatment requires a very judicious selection of ASMs aiming at reducing seizure burden along with management of the underlying condition.
Collapse
|
25
|
[S2k guidelines: status epilepticus in adulthood : Guidelines of the German Society for Neurology]. DER NERVENARZT 2021; 92:1002-1030. [PMID: 33751150 PMCID: PMC8484257 DOI: 10.1007/s00115-020-01036-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 01/16/2023]
Abstract
This S2k guideline on diagnosis and treatment of status epilepticus (SE) in adults is based on the last published version from 2021. New definitions and evidence were included in the guideline and the clinical pathway. A seizures lasting longer than 5 minutes (or ≥ 2 seizures over more than 5 mins without intermittend recovery to the preictal neurological state. Initial diagnosis should include a cCT or, if possible, an MRI. The EEG is highly relevant for diagnosis and treatment-monitoring of non-convulsive SE and for the exclusion or diagnosis of psychogenic non-epileptic seizures. As the increasing evidence supports the relevance of inflammatory comorbidities (e.g. pneumonia) related clinical chemistry should be obtained and repeated over the course of a SE treatment, and antibiotic therapy initiated if indicated.Treatment is applied on four levels: 1. Initial SE: An adequate dose of benzodiazepine is given i.v., i.m., or i.n.; 2. Benzodiazepine-refractory SE: I.v. drugs of 1st choice are levetiracetam or valproate; 3. Refractory SE (RSE) or 4. Super-refractory SE (SRSE): I.v. propofol or midazolam alone or in combination or thiopental in anaesthetic doses are given. In focal non-convulsive RSE the induction of a therapeutic coma depends on the circumstances and is not mandatory. In SRSE the ketogenic diet should be given. I.v. ketamine or inhalative isoflorane can be considered. In selected cased electroconvulsive therapy or, if a resectable epileptogenic zone can be defined epilepsy surgery can be applied. I.v. allopregnanolone or systemic hypothermia should not be used.
Collapse
|
26
|
Lim SN, Wu T, Tseng WEJ, Chiang HI, Cheng MY, Lin WR, Lin CN. Efficacy and safety of perampanel in refractory and super-refractory status epilepticus: cohort study of 81 patients and literature review. J Neurol 2021; 268:3744-3757. [PMID: 33754209 DOI: 10.1007/s00415-021-10506-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND The effective dose of perampanel in status epilepticus (SE), refractory SE (RSE), and super-refractory SE (SRSE) in humans is unknown, and the potential of perampanel in treating SE has not been evaluated in a large cohort. METHODS Data of intensive care patients with RSE and SRSE treated with perampanel were retrospectively reviewed and analyzed. RESULTS Eighty-one patients received perampanel, including 39 females with median age 64 [17-91] years, perampanel responders (n = 27), and non-responders (n = 54). The initial perampanel dose was positively associated with treatment response in patients with RSE or SRSE (OR = 1.27, 95% CI 1.03-1.57, p = 0.025), while the maximum dose was negatively associated with treatment response (OR = 0.74, 95% CI 0.58-0.96, p = 0.022). Hypoxia caused seizures in six patients; five died in hospital and one had severe disability. A statistically non-significant tendency toward better response was found in patients with unique SE type and cause, particularly in nonconvulsive status epilepticus (NCSE) without coma (NCSE without coma vs. generalized tonic-clonic seizure: OR = 4.14, 95% CI 0.98-17.47, p = 0.053). In the high-dose (≥ 16 mg/day) groups, although distributions of modified Rankin Scale (mRS) scores were similar between perampanel responders and non-responders at discharge, a greater proportion of perampanel responders had less change in mRS scores from baseline than did perampanel non-responders (median mRS: 0 vs 4, p = 0.064). No cardiorespiratory adverse events or laboratory abnormalities were noted with perampanel treatment. CONCLUSIONS Perampanel is effective and has a satisfactory safety profile in the emergency treatment of established RSE and SRSE.
Collapse
Affiliation(s)
- Siew-Na Lim
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fu-Shin Street, Kwei-Shan, Taoyuan, 333, Taiwan.
| | - Tony Wu
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fu-Shin Street, Kwei-Shan, Taoyuan, 333, Taiwan
- Department of Neurology, Xiamen Chang Gung Hospital, Xiamen, Fujian, China
| | - Wei-En Johnny Tseng
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fu-Shin Street, Kwei-Shan, Taoyuan, 333, Taiwan
- Biomedical Engineering, Chang Gung University, Taoyuan, Taiwan
| | - Hsing-I Chiang
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fu-Shin Street, Kwei-Shan, Taoyuan, 333, Taiwan
| | - Mei-Yun Cheng
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fu-Shin Street, Kwei-Shan, Taoyuan, 333, Taiwan
| | - Wey-Ran Lin
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chia-Ni Lin
- Department of Laboratory Medicine, Chang Gung Memorial Hospital at Linkou Medical Center, Taoyuan, Taiwan
- Department of Medical Biotechnology and Laboratory Science, Chang Gung University, Taoyuan, Taiwan
| |
Collapse
|
27
|
Ochoa JG, Dougherty M, Papanastassiou A, Gidal B, Mohamed I, Vossler DG. Treatment of Super-Refractory Status Epilepticus: A Review. Epilepsy Curr 2021; 21:1535759721999670. [PMID: 33719651 PMCID: PMC8652329 DOI: 10.1177/1535759721999670] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Super-refractory status epilepticus (SRSE) presents management challenges due to the absence of randomized controlled trials and a plethora of potential medical therapies. The literature on treatment options for SRSE reports variable success and quality of evidence. This review is a sequel to the 2020 American Epilepsy Society (AES) comprehensive review of the treatment of convulsive refractory status epilepticus (RSE). METHODS We sought to determine the effectiveness of treatment options for SRSE. We performed a structured literature search (MEDLINE, Embase, CENTRAL, CINAHL) for studies on reported treatments of SRSE. We excluded antiseizure medications (ASMs) covered in the 2016 AES guideline on the treatment of established SE and the convulsive RSE comprehensive review of the 2020 AES. Literature was reviewed on the effectiveness of vagus nerve stimulation, ketogenic diet (KD), lidocaine, inhalation anesthetics, brain surgery, therapeutic hypothermia, perampanel, pregabalin (PGB), and topiramate in the treatment of SRSE. Two authors reviewed each therapeutic intervention. We graded the level of the evidence according to the 2017 classification scheme of the American Academy of Neurology. RESULTS For SRSE (level U; 39 class IV studies total), insufficient evidence exists to support that perampanel, PGB, lidocaine, or acute vagus nerve stimulation (VNS) is effective. For children and adults with SRSE, insufficient evidence exists to support that the KD is effective (level U; 5 class IV studies). For adults with SRSE, insufficient evidence exists that brain surgery is effective (level U, 7 class IV studies). For adults with SRSE insufficient, evidence exists that therapeutic hypothermia is effective (level C, 1 class II and 4 class IV studies). For neonates with hypoxic-ischemic encephalopathy, insufficient evidence exists that therapeutic hypothermia reduces seizure burden (level U; 1 class IV study). For adults with SRSE, insufficient evidence exists that inhalation anesthetics are effective (level U, 1 class IV study) and that there is a potential risk of neurotoxicity. CONCLUSION For patients with SRSE insufficient, evidence exists that any of the ASMs reviewed, inhalational anesthetics, ketogenic diet, acute VNS, brain surgery, and therapeutic hypothermia are effective treatments. Data supporting the use of these treatments for SRSE are scarce and limited mainly to small case series and case reports and are confounded by differences in patients' population, and comedications, among other factors.
Collapse
Affiliation(s)
| | | | | | | | - Ismail Mohamed
- Department of Pediatrics, University of Alabama, Birmingham, USA
| | - David G. Vossler
- University of Washington, Seattle, WA, USA
- Treatments Committee, American Epilepsy Society, Chicago, IL, USA
| |
Collapse
|
28
|
Mantoan Ritter L, Nashef L. New-onset refractory status epilepticus (NORSE). Pract Neurol 2021; 21:practneurol-2020-002534. [PMID: 33674412 DOI: 10.1136/practneurol-2020-002534] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2021] [Indexed: 11/04/2022]
Abstract
New-onset refractory status epilepticus and its subcategory febrile infection-related epilepsy syndrome are rare devastating clinical presentations in those without pre-existing relevant history, often in schoolchildren or young adults, without a clear cause on initial investigations. A cause is later identified in up to half of adults, but in many fewer children. Patients often require protracted intensive care and are at significant risk of dying. Functional disability is common and subsequent chronic epilepsy is the norm, but some people do have good outcomes, even after prolonged status epilepticus. Patients need prompt investigations and treatment. Anaesthetic and antiseizure medications are supplemented by other treatment modalities, including the ketogenic diet. Despite limited evidence, it is appropriate to try to modify the presumed underlying pathogenesis with immune modulation early, with a more recent focus on using interleukin inhibitors. Optimising management will require concerted multicentre international efforts.
Collapse
Affiliation(s)
- Laura Mantoan Ritter
- Department of Neurology, King's College Hospital, London, UK
- Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK
| | - Lina Nashef
- Department of Neurology, King's College Hospital, London, UK
| |
Collapse
|
29
|
Kimura S, Shiraishi H, Egawa K, Uchida M, Ueno M. Efficacy of perampanel for epileptic seizures and daily behavior in a patient with Leigh syndrome: A case report. Brain Dev 2021; 43:157-159. [PMID: 32739100 DOI: 10.1016/j.braindev.2020.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 07/08/2020] [Accepted: 07/12/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Leigh syndrome (LS) is a mitochondrial disorder that shows abnormal basal ganglia lesion and psychomotor regression. Although vitamins have been used for LS, we have not found any effective drug. CASE PRESENTATION A 26-year-old man who showed psychomotor delay and short stature at the age of 1 year was diagnosed with LS according to the results of cerebrospinal fluid and high signal intensity in the bilateral striatum on T2-weighted magnetic resonance imaging. He demonstrated psychomotor delay and breathing disorders, but the progression was very slow. His symptoms suddenly worsened at the age of 24 years after acute epididymitis. He showed epileptic seizures simultaneously and his activities of daily living (ADL) significantly worsened. Several antiepileptic drugs were ineffective, but his seizures were suppressed by a low dose of perampanel and his ADL improved. CONCLUSION AND DISCUSSION Our case showed that low-dose perampanel could be a drug for epileptic seizures and improvement of ADL in patients with LS.
Collapse
Affiliation(s)
- Shuhei Kimura
- Department of Pediatrics, Oji General Hospital, Japan; Department of Pediatrics, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan.
| | - Hideaki Shiraishi
- Department of Pediatrics, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| | - Kiyoshi Egawa
- Department of Pediatrics, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| | - Masaya Uchida
- Department of Pediatrics, Nikko Memorial Hospital, Japan
| | - Michihiko Ueno
- Department of Pediatrics, Nikko Memorial Hospital, Japan
| |
Collapse
|
30
|
Dhir A, Bruun DA, Guignet M, Tsai Y, González E, Calsbeek J, Vu J, Saito N, Tancredi DJ, Harvey DJ, Lein PJ, Rogawski MA. Allopregnanolone and perampanel as adjuncts to midazolam for treating diisopropylfluorophosphate-induced status epilepticus in rats. Ann N Y Acad Sci 2020; 1480:183-206. [PMID: 32915470 PMCID: PMC7756871 DOI: 10.1111/nyas.14479] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/29/2020] [Accepted: 08/06/2020] [Indexed: 12/11/2022]
Abstract
Combinations of midazolam, allopregnanolone, and perampanel were assessed for antiseizure activity in a rat diisopropylfluorophosphate (DFP) status epilepticus model. Animals receiving DFP followed by atropine and pralidoxime exhibited continuous high-amplitude rhythmical electroencephalography (EEG) spike activity and behavioral seizures for more than 5 hours. Treatments were administered intramuscularly 40 min after DFP. Seizures persisted following midazolam (1.8 mg/kg). The combination of midazolam with either allopregnanolone (6 mg/kg) or perampanel (2 mg/kg) terminated EEG and behavioral status epilepticus, but the onset of the perampanel effect was slow. The combination of midazolam, allopregnanolone, and perampanel caused rapid and complete suppression of EEG and behavioral seizures. In the absence of DFP, animals treated with the three-drug combination were sedated but not anesthetized. Animals that received midazolam alone exhibited spontaneous recurrent EEG seizures, whereas those that received the three-drug combination did not, demonstrating antiepileptogenic activity. All combination treatments reduced neurodegeneration as assessed with Fluoro-Jade C staining to a greater extent than midazolam alone, and most reduced astrogliosis as assessed by GFAP immunoreactivity but had mixed effects on markers of microglial activation. We conclude that allopregnanolone, a positive modulator of the GABAA receptor, and perampanel, an AMPA receptor antagonist, are potential adjuncts to midazolam in the treatment of benzodiazepine-refractory organophosphate nerve agent-induced status epilepticus.
Collapse
Affiliation(s)
- Ashish Dhir
- Department of Neurology, School of MedicineUniversity of California, DavisSacramentoCalifornia
| | - Donald A. Bruun
- Department of Molecular Biosciences, School of Veterinary MedicineUniversity of California, DavisDavisCalifornia
| | - Michelle Guignet
- Department of Molecular Biosciences, School of Veterinary MedicineUniversity of California, DavisDavisCalifornia
| | - Yi‐Hua Tsai
- Department of Molecular Biosciences, School of Veterinary MedicineUniversity of California, DavisDavisCalifornia
| | - Eduardo González
- Department of Molecular Biosciences, School of Veterinary MedicineUniversity of California, DavisDavisCalifornia
| | - Jonas Calsbeek
- Department of Molecular Biosciences, School of Veterinary MedicineUniversity of California, DavisDavisCalifornia
| | - Joan Vu
- Department of Molecular Biosciences, School of Veterinary MedicineUniversity of California, DavisDavisCalifornia
| | - Naomi Saito
- Department of Public Health Sciences, School of MedicineUniversity of California, DavisDavisCalifornia
| | - Daniel J. Tancredi
- Department of Pediatrics, School of MedicineUniversity of California, DavisSacramentoCalifornia
| | - Danielle J. Harvey
- Department of Public Health Sciences, School of MedicineUniversity of California, DavisDavisCalifornia
| | - Pamela J. Lein
- Department of Molecular Biosciences, School of Veterinary MedicineUniversity of California, DavisDavisCalifornia
| | - Michael A. Rogawski
- Department of Neurology, School of MedicineUniversity of California, DavisSacramentoCalifornia
| |
Collapse
|
31
|
Willems LM, Bauer S, Jahnke K, Voss M, Rosenow F, Strzelczyk A. Therapeutic Options for Patients with Refractory Status Epilepticus in Palliative Settings or with a Limitation of Life-Sustaining Therapies: A Systematic Review. CNS Drugs 2020; 34:801-826. [PMID: 32705422 PMCID: PMC8316215 DOI: 10.1007/s40263-020-00747-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Refractory status epilepticus (RSE) represents a serious medical condition requiring early and targeted therapy. Given the increasing number of elderly or multimorbid patients with a limitation of life-sustaining therapy (LOT) or within a palliative care setting (PCS), guidelines-oriented therapy escalation options for RSE have to be omitted frequently. OBJECTIVES This systematic review sought to summarize the evidence for fourth-line antiseizure drugs (ASDs) and other minimally or non-invasive therapeutic options beyond guideline recommendations in patients with RSE to elaborate on possible treatment options for patients undergoing LOT or in a PCS. METHODS A systematic review of the literature in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, focusing on fourth-line ASDs or other minimally or non-invasive therapeutic options was performed in February and June 2020 using the MEDLINE, EMBASE and Cochrane databases. The search terminology was constructed using the name of the specific ASD or therapy option and the term 'status epilepticus' with the use of Boolean operators, e.g. "(brivaracetam) AND (status epilepticus)". The respective Medical Subject Headings (MeSH) and Emtree terms were used, if available. RESULTS There is currently no level 1, grade A evidence for the use of ASDs in RSE. The best evidence was found for the use of lacosamide and topiramate (level 3, grade C), followed by brivaracetam, perampanel (each level 4, grade D) and stiripentol, oxcarbazepine and zonisamide (each level 5, grade D). Regarding non-medicinal options, there is little evidence for the use of the ketogenic diet (level 4, grade D) and magnesium sulfate (level 5, grade D) in RSE. The broad use of immunomodulatory or immunosuppressive treatment options in the absence of a presumed autoimmune etiology cannot be recommended; however, if an autoimmune etiology is assumed, steroid pulse, intravenous immunoglobulins and plasma exchange/plasmapheresis should be considered (level 4, grade D). Even if several studies suggested that the use of neurosteroids (level 5, grade D) is beneficial in RSE, the current data situation indicates that there is formal evidence against it. CONCLUSIONS RSE in patients undergoing LOT or in a PCS represents a challenge for modern clinicians and epileptologists. The evidence for the use of ASDs in RSE beyond that in current guidelines is low, but several effective and well-tolerated options are available that should be considered in this patient population. More so than in any other population, advance care planning, advance directives, and medical ethical aspects have to be considered carefully before and during therapy.
Collapse
Affiliation(s)
- Laurent M Willems
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany.
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany.
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany.
| | - Sebastian Bauer
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Kolja Jahnke
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Martin Voss
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- Dr. Senckenberg Institute of Neuro-Oncology, Goethe University Frankfurt, University Hospital Frankfurt, Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
- Department of Neurology, Epilepsy Center Hessen, Philipps University Marburg, Marburg (Lahn), Germany
| |
Collapse
|
32
|
Treatment of status epilepticus with zonisamide: A multicenter cohort study of 34 patients and review of literature. Epilepsy Behav 2020; 109:107139. [PMID: 32417381 DOI: 10.1016/j.yebeh.2020.107139] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 04/22/2020] [Accepted: 04/24/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION We present a summary of clinical cases of oral zonisamide (ZNS) used to treat refractory and super-refractory episodes of status epilepticus (SE). METHODS Zonisamide administration in SE was identified in the clinical records of patients treated in Frankfurt and Marburg between 2011 and 2017. RESULTS Zonisamide was administered during a total of 37 SE episodes in 34 patients with a mean age of 58.7 ± 17.8 years, 21 of them were female (61.7%). The median latency from the onset of SE to administration of ZNS was 6.3 days. Patients had already undergone unsuccessful treatment with a median of three other antiseizure drugs (ASDs). The median initial dose of ZNS was 100 mg/d, titrated to a median maintenance dose of 400 mg/d. Patients underwent ZNS treatment for a median period of 7 days. Zonisamide was the final drug administered in 9 of 37 (24.3%) episodes, with a clinical effect attributed to ZNS observed in 6 of 37 (16.2%) episodes. An effect attributed to ZNS was observed in 5 out of 30 episodes of refractory SE (RSE) and in one out of 7 episodes of super-refractory SE (SRSE). Possible negative side effects of ZNS were observed in two patients (one patient each with ataxia and skin rash). The mortality rate in hospitalized patients was 10.4% (n = 4). CONCLUSION The rate of SE resolution attributed to ZNS treatment (16.2%) can be considered relevant, particularly since ZNS treatment tends to be administered only after several other options have been tried, and has a treatment latency of over six days. Zonisamide may therefore be considered as an alternative oral treatment option in RSE and SRSE.
Collapse
|
33
|
Fechner A, Hubert K, Jahnke K, Knake S, Konczalla J, Menzler K, Ronellenfitsch MW, Rosenow F, Strzelczyk A. Treatment of refractory and superrefractory status epilepticus with topiramate: A cohort study of 106 patients and a review of the literature. Epilepsia 2019; 60:2448-2458. [DOI: 10.1111/epi.16382] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 10/16/2019] [Accepted: 10/18/2019] [Indexed: 01/08/2023]
Affiliation(s)
- Anne Fechner
- Department of Neurology Epilepsy Center Frankfurt Rhine‐Main Goethe University Frankfurt Frankfurt am Main Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER) Goethe University Frankfurt Frankfurt am Main Germany
| | - Kristina Hubert
- Department of Neurology Epilepsy Center Frankfurt Rhine‐Main Goethe University Frankfurt Frankfurt am Main Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER) Goethe University Frankfurt Frankfurt am Main Germany
| | - Kolja Jahnke
- Department of Neurology Epilepsy Center Frankfurt Rhine‐Main Goethe University Frankfurt Frankfurt am Main Germany
| | - Susanne Knake
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER) Goethe University Frankfurt Frankfurt am Main Germany
- Department of Neurology Epilepsy Center Hessen Philipps University Marburg Marburg (Lahn) Germany
| | - Jürgen Konczalla
- Department of Neurosurgery Goethe University Frankfurt Frankfurt am Main Germany
| | - Katja Menzler
- Department of Neurology Epilepsy Center Hessen Philipps University Marburg Marburg (Lahn) Germany
| | - Michael W. Ronellenfitsch
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER) Goethe University Frankfurt Frankfurt am Main Germany
- Dr Senckenberg Institute of Neurooncology Goethe University Frankfurt Frankfurt am Main Germany
- Frankfurt Cancer Institute Goethe University Frankfurt Frankfurt am Main Germany
| | - Felix Rosenow
- Department of Neurology Epilepsy Center Frankfurt Rhine‐Main Goethe University Frankfurt Frankfurt am Main Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER) Goethe University Frankfurt Frankfurt am Main Germany
| | - Adam Strzelczyk
- Department of Neurology Epilepsy Center Frankfurt Rhine‐Main Goethe University Frankfurt Frankfurt am Main Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER) Goethe University Frankfurt Frankfurt am Main Germany
- Department of Neurology Epilepsy Center Hessen Philipps University Marburg Marburg (Lahn) Germany
| |
Collapse
|
34
|
Super-Refractory Status Epilepticus Treated with High Dose Perampanel: Case Series and Review of the Literature. Case Rep Crit Care 2019; 2019:3218231. [PMID: 31565443 PMCID: PMC6745135 DOI: 10.1155/2019/3218231] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 07/31/2019] [Indexed: 12/13/2022] Open
Abstract
Introduction Acute symptomatic seizures are frequent in the critically ill patient and can be difficult to treat. The novel anticonvulsant perampanel may be effective in the treatment of status epilepticus considering its mechanism of action of being an AMPA antagonist. We present four cases of super refractory status epilepticus treated with high dose perampanel. Method Case report. Cases Four patients were treated with perampanel for their refractory status epilepticus. One patient had new onset refractory status epilepticus of unknown etiology. Three other patients had status epilepticus as a result of their cardiac arrest. Two of the cardiac arrest patients had myoclonus. In all patients, the additional of perampanel resulted in a reduction of seizure burden without affecting hemodynamics or hepatic or renal function. Conclusion Perampanel may be effective in the treatment of super-refractory status epilepticus of varying etiologies. A larger, prospective study is needed to further assess this therapy.
Collapse
|
35
|
Willems LM, Bauer S, Rosenow F, Strzelczyk A. Recent advances in the pharmacotherapy of epilepsy: brivaracetam and perampanel as broad-spectrum antiseizure drugs for the treatment of epilepsies and status epilepticus. Expert Opin Pharmacother 2019; 20:1755-1765. [DOI: 10.1080/14656566.2019.1637420] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Laurent Maximilian Willems
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Sebastian Bauer
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany
| |
Collapse
|
36
|
Oral Perampanel for the Treatment of Super-Refractory Status Epilepticus. Case Rep Neurol Med 2019; 2019:8537815. [PMID: 31093391 PMCID: PMC6481131 DOI: 10.1155/2019/8537815] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 03/27/2019] [Indexed: 11/22/2022] Open
Abstract
A 72-year-old man presented with a super-refractory partial status epilepticus following evacuation of a right subdural hematoma. He failed to respond to treatment with high doses of intravenous valproic acid, Levetiracetam, Lacosamide, Thiopental, and Midazolam. He was given 4 mg of Perampanel orally via nasogastric tube and the dose was rapidly increased to 8 mg after 12 hours with cessation of clinical and electrical seizures. Other antiepileptic drugs were tapered progressively with an excellent clinical outcome.
Collapse
|
37
|
Strzelczyk A, Knake S, Kälviäinen R, Santamarina E, Toledo M, Willig S, Rohracher A, Trinka E, Rosenow F. Perampanel for treatment of status epilepticus in Austria, Finland, Germany, and Spain. Acta Neurol Scand 2019; 139:369-376. [PMID: 30613951 PMCID: PMC6590284 DOI: 10.1111/ane.13061] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 12/10/2018] [Accepted: 12/30/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Novel treatments are needed to control treatment-resistant status epilepticus (SE). We report a summary of clinical cases where perampanel was used in established SE, refractory SE (RSE), or super-refractory SE (SRSE). METHODS Medical records were retrospectively reviewed for perampanel administration in SE at five European hospitals between 2011 and 2015. RESULTS Of 1319 patients identified as experiencing SE, 52 (3.9%) received perampanel. Median latency from SE onset to perampanel initiation was 10 days. Patients with SE had previously failed benzodiazepines (when received) and a median of five other antiepileptic drugs (AEDs). Median initial perampanel dose was 6 mg/d, up-titrated to a median maximum dose of 10 mg/d. Perampanel was the last drug added in 32/52 (61.5%) patients, with response attributed to perampanel in 19/52 (36.5%) patients. A greater proportion of perampanel non-responders had SRSE (51.5%; 17/33) vs perampanel responders (31.6%; 6/19), and had failed a higher mean number of AEDs before initiating perampanel (5.9 vs 5.1, respectively). Most commonly reported adverse effects during perampanel treatment were dizziness (n = 1 [1.9%]) and somnolence (n = 1 [1.9%]). No serious adverse effects were documented, and none led to discontinuation of perampanel. CONCLUSIONS Perampanel was administered to patients with established SE, RSE, or SRSE at greater initial doses than those administered in clinical practice to patients with epilepsy. The SE cases reported here represent a refractory and heterogeneous population, and rate of seizure cessation attributed to perampanel treatment (36.5%) represents a notable response. These data should be confirmed in a larger patient population.
Collapse
Affiliation(s)
- Adam Strzelczyk
- Department of Neurology, Epilepsy Center Frankfurt Rhine-Main; Goethe University; Frankfurt am Main Germany
- Department of Neurology, Epilepsy Center Hessen; Philipps University; Marburg Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER); Goethe University; Frankfurt am Main Germany
| | - Susanne Knake
- Department of Neurology, Epilepsy Center Hessen; Philipps University; Marburg Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER); Goethe University; Frankfurt am Main Germany
| | - Reetta Kälviäinen
- School of Medicine; University of Eastern Finland; Kuopio Finland
- Epilepsy Center/Neuro Center; Kuopio University Hospital; Kuopio Finland
| | | | - Manuel Toledo
- Epilepsy Unit; Hospital Vall d’Hebron; Barcelona Spain
| | - Sophia Willig
- Department of Neurology, Epilepsy Center Frankfurt Rhine-Main; Goethe University; Frankfurt am Main Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER); Goethe University; Frankfurt am Main Germany
| | - Alexandra Rohracher
- Department of Neurology, Christian Doppler Klinik; Paracelsus Medical University; Salzburg Austria
- Centre for Cognitive Neuroscience; University of Salzburg; Salzburg Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik; Paracelsus Medical University; Salzburg Austria
- Centre for Cognitive Neuroscience; University of Salzburg; Salzburg Austria
- Department of Public Health, Health Services Research and Health Technology Assessment; UMIT - University for Health Sciences, Medical Informatics and Technology; Hall in Tirol Austria
| | - Felix Rosenow
- Department of Neurology, Epilepsy Center Frankfurt Rhine-Main; Goethe University; Frankfurt am Main Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER); Goethe University; Frankfurt am Main Germany
| |
Collapse
|