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Zhang H, Ou Z, Zhang E, Liu W, Hao N, Chen Y, Liu Y, Ye H, Zhou D, Wu X. Efficacy and safety of add-on antiseizure medications for focal epilepsy: A network meta-analysis. Epilepsia Open 2024. [PMID: 38888005 DOI: 10.1002/epi4.12997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/26/2024] [Accepted: 06/04/2024] [Indexed: 06/20/2024] Open
Abstract
OBJECTIVE Several antiseizure medications (ASMs) have been approved for the treatment of focal epilepsy. However, there is a paucity of evidence on direct comparison of ASMs. We evaluated the comparative efficacy and safety of all approved add-on ASMs for the treatment of focal epilepsy using network meta-analysis. METHODS Data through extensive literature search was retrieved from PubMed, Embase, Cochrane, and ClinicalTrial.gov databases using predefined search terms from inception through March 2023. PRISMA reporting guidelines (CRD42023403450) were followed in this study. Efficacy outcomes assessed were ≥50%, ≥75%, and 100% responder rates. Patient retention rate and safety outcomes such as overall treatment-emergent adverse events (TEAEs) and individual TEAEs were assessed. "Gemtc" 4.0.4 package was used to perform Bayesian analysis. Outcomes are reported as relative risks (RRs) and 95% confidence interval (CI). RESULTS Literature search retrieved 5807 studies of which, 75 studies were included in the analysis. All ASMs showed significantly higher ≥50% responder rate compared with placebo. Except the ≥75% seizure frequency reduction for zonisamide (2.23; 95% CI: 1.00-5.70) and 100% for rufinamide (2.03; 95% CI: 0.54-11.00), all other interventions showed significantly higher ≥75% and 100% responder rates compared with placebo. Among treatments, significantly higher 100% responder rate was observed with cenobamate compared to eslicarbazepine (10.71; 95% CI: 1.56-323.9) and zonisamide (10.63; 95% CI: 1.37-261.2). All ASMs showed a lower patient retention rate compared to placebo, with the least significant value observed for oxcarbazepine (0.77; 95% CI: 0.7-0.84). Levetiracetam showed a lower risk of incidence (1.0; 95%CI: 0.94-1.1; SUCRA: 0.885067) for overall TEAE compared with other medications. SIGNIFICANCE All approved ASMs were effective as add-on treatment for focal epilepsy. Of the ASMs included, cenobamate had the greatest likelihood of allowing patients to attain seizure freedom. PLAIN LANGUAGE SUMMARY This article compares the efficacy and safety of antiseizure medications (ASMs) currently available to neurologists in the treatment of epileptic patients. Several newer generation ASMs that have been developed may be as effective or better than the older medications. We included 75 studies in the analysis. In comparison, all drugs improved ≥50%, ≥75% and 100% responder rates compared to control, except for Zonisamide and Rufinamide in the ≥75% and 100% responder rate categories. Retention of patients undergoing treatment was lower in drugs than placebo. All drugs were tolerated, the levetiracetam showed the best tolerability. Cenobamate more likely help completely to reduce seizures.
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Affiliation(s)
- Hesheng Zhang
- Neurology Department, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Zhujing Ou
- Neurology Department, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Enhui Zhang
- Neurology Department, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Wenyu Liu
- Neurology Department, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Nanya Hao
- Neurology Department, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yujie Chen
- Neurology Department, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yutong Liu
- Ignis Therapeutics (Shanghai) Limited, Shanghai, China
| | - Hui Ye
- Ignis Therapeutics (Shanghai) Limited, Shanghai, China
| | - Dong Zhou
- Neurology Department, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Xintong Wu
- Neurology Department, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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Schmitz B, Lattanzi S, Vonck K, Kälviäinen R, Nashef L, Ben‐Menachem E. Cenobamate in refractory epilepsy: Overview of treatment options and practical considerations. Epilepsia Open 2023; 8:1241-1255. [PMID: 37743544 PMCID: PMC10690671 DOI: 10.1002/epi4.12830] [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: 05/24/2023] [Accepted: 09/18/2023] [Indexed: 09/26/2023] Open
Abstract
Management of drug resistant epilepsy (DRE) represents a challenge to the treating clinician. This manuscript addresses DRE and provides an overview of treatment options, medical, surgical, and dietary. It addresses treatment strategies in polytherapy, then focuses on the role cenobamate (CNB) may play in reducing the burden of DRE while providing practical advice for its introduction. CNB is a recently approved, third generation, anti-seizure medication (ASM), a tetrazole-derived carbamate, thought to have a dual mechanism of action, through its effect on sodium channels as well as on GABAA receptors at a non-benzodiazepine site. CNB, having a long half-life, is an effective add-on ASM in refractory focal epilepsy with a higher response rate and a higher seizure-freedom rate than is usually seen in regulatory clinical trials. Experience post-licensing, though still limited, supports the findings of clinical trials and is encouraging. Its spectrum of action in relation to generalized epilepsies and seizures remains to be established, and there are no data on its efficacy in monotherapy. At the time of writing, CNB has been prescribed for some 50 000 individuals with DRE and focal epilepsy. A larger number is needed to fully establish its safety profile. It should at all times be introduced slowly to minimize the risk of serious allergic drug reactions. It has clinically meaningful interactions which must be anticipated and managed to maximize tolerability and likelihood of successful treatment. Despite the above, it may well prove to be of major benefit in the treatment of many patients with drug resistant epilepsy.
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Affiliation(s)
- Bettina Schmitz
- Center for Epilepsy, Department for NeurologyVivantes Humboldt‐KlinikumBerlinGermany
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical MedicineMarche Polytechnic UniversityAnconaItaly
| | - Kristl Vonck
- Department of Neurology, 4BrainGhent University HospitalGentBelgium
| | - Reetta Kälviäinen
- Kuopio Epilepsy Center, Kuopio University Hospital, Member of ERN EpiCARE, and Institute of Clinical MedicineUniversity of Eastern FinlandKuopioFinland
| | - Lina Nashef
- Neurology DepartmentKing's College HospitalLondonUK
| | - Elinor Ben‐Menachem
- Institution for Clinical Neuroscience, Sahlgrenska AcademyUniversity of GoteborgGoteborgSweden
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Kriechbaumer SRP, Jurina K, Wielaender F, Schenk HC, Steinberg TA, Reese S, Buhmann G, Doerfelt S, Potschka H, Fischer A. Pregabalin Add-On vs. Dose Increase in Levetiracetam Add-On Treatment: A Real-Life Trial in Dogs With Drug-Resistant Epilepsy. Front Vet Sci 2022; 9:910038. [PMID: 35873699 PMCID: PMC9298511 DOI: 10.3389/fvets.2022.910038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
Epilepsy is a common neurological disorder affecting 0.6–0.75% of dogs in veterinary practice. Treatment is frequently complicated by the occurrence of drug-resistant epilepsy and cluster seizures in dogs with idiopathic epilepsy. Only few studies are available to guide treatment choices beyond licensed veterinary drugs. The aim of the study was to compare antiseizure efficacy and tolerability of two add-on treatment strategies in dogs with drug-resistant idiopathic epilepsy. The study design was a prospective, open-label, non-blinded, comparative treatment trial. Treatment success was defined as a 3-fold extension of the longest baseline interseizure interval and to a minimum of 3 months. To avoid prolonged adherence to a presumably ineffective treatment strategy, dog owners could leave the study after the third day with generalized seizures if the interseizure interval failed to show a relevant increase. Twenty-six dogs (mean age 5.5 years, mean seizure frequency 4/month) with drug-resistant idiopathic epilepsy and a history of cluster seizures were included. Dogs received either add-on treatment with pregabalin (PGB) 4 mg/kg twice daily (14 dogs) or a dose increase in levetiracetam (LEV) add-on treatment (12 dogs). Thirteen dogs in the PGB group had drug levels within the therapeutic range for humans. Two dogs in the PGB group (14.3%; 2/14) and one dog in the LEV group (8.3%; 1/12) achieved treatment success with long seizure-free intervals from 122 to 219 days but then relapsed to their early seizure frequency 10 months after the study inclusion. The overall low success rates with both treatment strategies likely reflect a real-life situation in canine drug-resistant idiopathic epilepsy in everyday veterinary practice. These results delineate the need for research on better pharmacologic and non-pharmacologic treatment strategies in dogs with drug-resistant epilepsy.
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Affiliation(s)
- Sandra R. P. Kriechbaumer
- Centre for Clinical Veterinary Medicine, Clinic of Small Animal Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
- AniCura Small Animal Clinic Haar, Haar, Germany
| | | | - Franziska Wielaender
- Centre for Clinical Veterinary Medicine, Clinic of Small Animal Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Henning C. Schenk
- Centre for Clinical Veterinary Medicine, Clinic of Small Animal Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
- Small Animal Clinic Lüneburg, Lüneburg, Germany
| | | | - Sven Reese
- Department of Veterinary Sciences, Institute of Anatomy, Histology and Embryology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Gesine Buhmann
- Centre for Clinical Veterinary Medicine, Clinic of Small Animal Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Stefanie Doerfelt
- Centre for Clinical Veterinary Medicine, Clinic of Small Animal Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
- AniCura Small Animal Clinic Haar, Haar, Germany
| | - Heidrun Potschka
- Department of Veterinary Sciences, Institute of Pharmacology, Toxicology, and Pharmacy, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Andrea Fischer
- Centre for Clinical Veterinary Medicine, Clinic of Small Animal Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
- *Correspondence: Andrea Fischer
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Abstract
BACKGROUND This is an updated version of the Cochrane Review last published in Issue 7, 2019; it includes two additional studies. Epilepsy is a common neurological disease that affects approximately 1% of the UK population. Approximately one-third of these people continue to have seizures despite drug treatment. Pregabalin is one of the newer antiepileptic drugs that has been developed to improve outcomes. In this review we summarised the current evidence regarding pregabalin when used as an add-on treatment for drug-resistant focal epilepsy. OBJECTIVES To assess the efficacy and tolerability of pregabalin when used as an add-on treatment for drug-resistant focal epilepsy. SEARCH METHODS For the latest update we searched the following databases on 16 November 2020: Cochrane Register of Studies (CRS Web), and MEDLINE (Ovid, 1946 to 16 November 2020). CRS Web includes randomised or quasi-randomised, controlled trials from PubMed, Embase, ClinicalTrials.gov, the World Health Organisation International Clinical Trials Registry Platform (ICTRP), the Cochrane Central Register of Controlled Trials (CENTRAL), and the Specialised Registers of Cochrane Review Groups, including Epilepsy. We imposed no language restrictions. We contacted the manufacturers of pregabalin and authors in the field to identify any relevant unpublished studies. SELECTION CRITERIA We included randomised controlled trials comparing pregabalin with placebo or an alternative antiepileptic drug as an add-on for people of any age with drug-resistant focal epilepsy. Double-blind and single-blind trials were eligible for inclusion. The primary outcome was 50% or greater reduction in seizure frequency; secondary outcomes were seizure freedom, treatment withdrawal for any reason, treatment withdrawal due to adverse effects, and proportion of individuals experiencing adverse effects. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion and extracted the relevant data. Primary analyses were intention-to-treat (ITT). We presented summary risk ratios (RRs) and odds ratios (ORs) with 95% confidence intervals (CIs). We evaluated dose response in regression models. We carried out a risk of bias assessment for each included study using the Cochrane risk of bias tool and assessed the overall certainty of evidence using the GRADE approach. MAIN RESULTS We included 11 randomised controlled trials (3949 participants). Nine trials compared pregabalin to placebo. For the primary outcome, participants randomised to pregabalin were significantly more likely to attain a 50% or greater reduction in seizure frequency compared to placebo (RR 1.95, 95% CI 1.40 to 2.72, 9 trials, 2663 participants, low-certainty evidence). The odds of response doubled with an increase in dose from 300 mg/day to 600 mg/day (OR 1.99, 95% CI 1.74 to 2.28), indicating a dose-response relationship. Pregabalin was significantly associated with seizure freedom (RR 3.94, 95% CI 1.50 to 10.37, 4 trials, 1125 participants, moderate-certainty evidence). Participants were significantly more likely to withdraw from pregabalin treatment than placebo for any reason (RR 1.33, 95% CI 1.10 to 1.60; 9 trials, 2663 participants; moderate-certainty evidence) and for adverse effects (RR 2.60, 95% CI 1.86 to 3.64; 9 trials, 2663 participants; moderate-certainty evidence). Three trials compared pregabalin to three active-control drugs: lamotrigine, eventrate and gabapentin. Participants allocated to pregabalin were significantly more likely to achieve a 50% or greater reduction in seizure frequency than those allocated to lamotrigine (RR 1.47, 95% CI 1.03 to 2.12; 1 trial, 293 participants) but not those allocated to eventrate (RR 0.94, 95% CI 0.80 to 1.11; 1 trial, 509 participants) or gabapentin (RR 0.96, 95% CI 0.82 to 1.12; 1 trial, 484 participants). We found no significant differences between pregabalin and lamotrigine for seizure freedom (RR 1.39, 95% CI 0.40 to 4.83). However, significantly fewer participants achieved seizure freedom with add-on pregabalin compared to eventrate (RR 0.50, 95% CI 0.30 to 0.85). No data were reported for this outcome for pregabalin versus gabapentin. We detected no significant differences in treatment withdrawal rate for any reason or due to adverse effects, specifically, during either pooled analysis or subgroup analysis. Ataxia, dizziness, somnolence, weight gain, headache and fatigue were significantly associated with pregabalin than in active control. We rated the overall risk of bias in the included studies as low or unclear due to the possibility of publication bias and lack of methodological details provided. We assessed all the studies to be at a high risk of funding bias as they were all sponsored by Pfizer. We rated the certainty of the evidence as very low to moderate using the GRADE approach. AUTHORS' CONCLUSIONS For people with drug-resistant focal epilepsy, pregabalin when used as an add-on treatment was significantly more effective than placebo at producing a 50% or greater seizure reduction and seizure freedom. Results demonstrated efficacy for doses from 150 mg/day to 600 mg/day, with increasing effectiveness at 600 mg doses, although there were issues with tolerability at higher doses. However, the trials included in this review were of short duration, and longer-term trials are needed to inform clinical decision-making. This review focused on the use of pregabalin in drug-resistant focal epilepsy, and the results cannot be generalised to add-on treatment for generalised epilepsies. Likewise, no inference can be made about the effects of pregabalin when used as monotherapy.
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Affiliation(s)
- Mariangela Panebianco
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Rebecca Bresnahan
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
- Liverpool Reviews and Implementation Group, Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Anthony G Marson
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
- The Walton Centre NHS Foundation Trust, Liverpool, UK
- Liverpool Health Partners, Liverpool, UK
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Zapf A, Asendorf T, Anten C, Mütze T, Friede T. Blinded sample size reestimation for negative binomial regression with baseline adjustment. Stat Med 2020; 39:1980-1998. [PMID: 32207171 DOI: 10.1002/sim.8525] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 02/05/2020] [Accepted: 02/24/2020] [Indexed: 12/25/2022]
Abstract
In randomized clinical trials, it is standard to include baseline variables in the primary analysis as covariates, as it is recommended by international guidelines. For the study design to be consistent with the analysis, these variables should also be taken into account when calculating the sample size to appropriately power the trial. Because assumptions made in the sample size calculation are always subject to some degree of uncertainty, a blinded sample size reestimation (BSSR) is recommended to adjust the sample size when necessary. In this article, we introduce a BSSR approach for count data outcomes with baseline covariates. Count outcomes are common in clinical trials and examples include the number of exacerbations in asthma and chronic obstructive pulmonary disease, relapses, and scan lesions in multiple sclerosis and seizures in epilepsy. The introduced methods are based on Wald and likelihood ratio test statistics. The approaches are illustrated by a clinical trial in epilepsy. The BSSR procedures proposed are compared in a Monte Carlo simulation study and shown to yield power values close to the target while not inflating the type I error rate.
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Affiliation(s)
- Antonia Zapf
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany.,Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Asendorf
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Christoph Anten
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Tobias Mütze
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany.,Statistical Methodology, Novartis Pharma AG, Basel, Switzerland
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
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Morano A, Palleria C, Citraro R, Nesci V, De Caro C, Giallonardo AT, De Sarro G, Russo E, Di Bonaventura C. Immediate and controlled-release pregabalin for the treatment of epilepsy. Expert Rev Neurother 2019; 19:1167-1177. [PMID: 31623493 DOI: 10.1080/14737175.2019.1681265] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: Epilepsy is a common neurological disease requiring complex therapies, which are unable to achieve seizure control in 30% of patients. Poor adherence has been recognized as a possible determinant of drug-resistance. Prolonged-release formulations of antiepileptic drugs might help increase adherence and minimize side effects.Areas covered: Pregabalin (PGB) has peculiar pharmacodynamics and almost ideal pharmacokinetics, except for a short half-life and therefore requiring multiple daily dosing. PGB immediate-release (IR) is effective in focal-onset epilepsy (FOE), neuropathic pain, generalized anxiety disorder, and fibromyalgia, despite some tolerability issues, especially at higher doses. The controlled-release formulation (CR) shares PGB IR advantages and requires slight dose adjustments to guarantee bioavailability. In 2014, PGB CR (165 and 330 mg/day) failed to prove superior to placebo in a randomized placebo-controlled trial on 323 subjects with drug-resistant FOE, although it was just as tolerable. Therefore, PGB CR is not currently licensed for epilepsy.Expert opinion: Considering the disappointing results of the only controlled trial, PGB CR is unlikely to become an established epilepsy treatment anytime soon. Nevertheless, given its peculiar properties and potential advantages, PGB (in either formulation) should be further evaluated in specific populations of patients, especially fragile subjects with several comorbidities and complex polytherapies.
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Affiliation(s)
- Alessandra Morano
- Neurology Unit, Department of Human Neurosciences, "Sapienza" University, Rome, Italy
| | - Caterina Palleria
- Science of Health Department, School of Medicine, University of Catanzaro, Catanzaro, Italy
| | - Rita Citraro
- Science of Health Department, School of Medicine, University of Catanzaro, Catanzaro, Italy
| | - Valentina Nesci
- Science of Health Department, School of Medicine, University of Catanzaro, Catanzaro, Italy
| | - Carmen De Caro
- Science of Health Department, School of Medicine, University of Catanzaro, Catanzaro, Italy
| | | | | | - Emilio Russo
- Science of Health Department, School of Medicine, University of Catanzaro, Catanzaro, Italy
| | - Carlo Di Bonaventura
- Neurology Unit, Department of Human Neurosciences, "Sapienza" University, Rome, Italy
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Abstract
BACKGROUND Epilepsy is a common neurological disease that affects approximately 1% of the UK population. Approximately one-third of these people continue to have seizures despite drug treatment. Pregabalin is one of the newer antiepileptic drugs which have been developed to improve outcomes.This is an updated version of the Cochrane Review published in Issue 3, 2014, and includes three new studies. OBJECTIVES To assess the efficacy and tolerability of pregabalin when used as an add-on treatment for drug-resistant focal epilepsy. SEARCH METHODS For the latest update we searched the Cochrane Register of Studies (CRS Web), which includes the Cochrane Epilepsy Group Specialized Register and the Cochrane Central Register of Controlled Trials (CENTRAL), on 5 July 2018, MEDLINE (Ovid, 1946 to 5 July 2018), ClinicalTrials.gov (5 July 2018), and the World Health Organization International Clinical Trials Registry Platform (ICTRP, 5 July 2018), and contacted Pfizer Ltd, manufacturer of pregabalin, to identify published, unpublished, and ongoing trials. SELECTION CRITERIA We included randomised controlled trials comparing pregabalin with placebo or an alternative antiepileptic drug as an add-on for people of any age with drug-resistant focal epilepsy. Double-blind and single-blind trials were eligible for inclusion. The primary outcome was 50% or greater reduction in seizure frequency; secondary outcomes were seizure freedom, treatment withdrawal for any reason, treatment withdrawal due to adverse effects, and proportion of individuals experiencing adverse effects. DATA COLLECTION AND ANALYSIS Two review authors independently selected and assessed trials for eligibility and extracted data. Analyses were by intention-to-treat. We presented results as risk ratios (RR) and odds ratios (OR) with 95% confidence intervals (CIs). Two review authors assessed the included studies for risk of bias using the Cochrane 'Risk of bias' tool. MAIN RESULTS We included nine industry-sponsored randomised controlled trials (3327 participants) in the review. Seven trials compared pregabalin to placebo. For the primary outcome, participants randomised to pregabalin were significantly more likely to attain a 50% or greater reduction in seizure frequency compared to placebo (RR 2.28, 95% CI 1.52 to 3.42, 7 trials, 2193 participants, low-certainty evidence). The odds of response doubled with an increase in dose from 300 mg/day to 600 mg/day (OR 1.99, 95% CI 1.74 to 2.28), indicating a dose-response relationship. Pregabalin was significantly associated with seizure freedom (RR 3.94, 95% CI 1.50 to 10.37, 4 trials, 1125 participants, moderate-certainty evidence). Participants were significantly more likely to withdraw from pregabalin treatment than placebo for any reason (RR 1.35, 95% CI 1.11 to 1.65, 7 trials, 2193 participants, moderate-certainty evidence) and for adverse effects (RR 2.65, 95% CI 1.88 to 3.74, 7 trials, 2193 participants, moderate-certainty evidence).Three trials compared pregabalin to three active-control drugs: lamotrigine, levetiracetam, and gabapentin. Participants allocated to pregabalin were significantly more likely to achieve a 50% or greater reduction in seizure frequency than those allocated to lamotrigine (RR 1.47, 95% CI 1.03 to 2.12, 1 trial, 293 participants) but not those allocated to levetiracetam (RR 0.94, 95% CI 0.80 to 1.11, 1 trial, 509 participants) or gabapentin (RR 0.96, 95% CI 0.82 to 1.12, 1 trial, 484 participants). We found no significant differences between pregabalin and lamotrigine (RR 1.39, 95% CI 0.40 to 4.83) for seizure freedom, however, significantly fewer participants achieved seizure freedom with add-on pregabalin compared to levetiracetam (RR 0.50, 95% CI 0.30 to 0.85). No data were reported for this outcome for pregabalin versus gabapentin. We found no significant differences between pregabalin and lamotrigine (RR 1.07, 95% CI 0.75 to 1.52), levetiracetam (RR 1.03, 95% CI 0.71 to 1.49), or gabapentin (RR 0.78, 95% CI 0.57 to 1.07) for treatment withdrawal due to any reason or due to adverse effects (pregabalin versus lamotrigine: RR 0.89, 95% CI 0.53 to 1.48; versus levetiracetam: RR 1.29, 95% CI 0.66 to 2.54; versus gabapentin: RR 1.07, 95% CI 0.54 to 2.11). Ataxia, dizziness, somnolence, weight gain, and fatigue were significantly associated with pregabalin.We rated the overall risk of bias in the included studies as low or unclear due to the possibility of publication bias and lack of methodological details provided. We rated the certainty of the evidence as very low to moderate using the GRADE approach. AUTHORS' CONCLUSIONS Pregabalin, when used as an add-on drug for treatment-resistant focal epilepsy, is significantly more effective than placebo at producing a 50% or greater seizure reduction and seizure freedom. Results demonstrated efficacy for doses from 150 mg/day to 600 mg/day, with increasing effectiveness at 600 mg doses, however issues with tolerability were noted at higher doses. The trials included in this review were of short duration, and longer-term trials are needed to inform clinical decision making.
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Affiliation(s)
- Mariangela Panebianco
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneLiverpoolUKL9 7LJ
| | - Rebecca Bresnahan
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneLiverpoolUKL9 7LJ
| | - Karla Hemming
- University of BirminghamPublic Health, Epidemiology and BiostatisticsEdgbastonBirminghamUKB15 2TT
| | - Anthony G Marson
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneLiverpoolUKL9 7LJ
- The Walton Centre NHS Foundation TrustLiverpoolUK
- Liverpool Heath PartnersLiverpoolUK
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Yi ZM, -, Wen C, Cai T, Xu L, Zhong XL, Zhan SY, Zhai SD. Levetiracetam for epilepsy: an evidence map of efficacy, safety and economic profiles. Neuropsychiatr Dis Treat 2018; 15:1-19. [PMID: 30587993 PMCID: PMC6301299 DOI: 10.2147/ndt.s181886] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy, safety and economics of levetiracetam (LEV) for epilepsy. MATERIALS AND METHODS PubMed, Scopus, the Cochrane Library, OpenGrey.eu and ClinicalTrials.gov were searched for systematic reviews (SRs), meta-analyses, randomized controlled trials (RCTs), observational studies, case reports and economic studies published from January 2007 to April 2018. We used a bubble plot to graphically display information of included studies and conducted meta-analyses to quantitatively synthesize the evidence. RESULTS A total of 14,803 records were obtained. We included 30 SRs/meta-analyses, 34 RCTs, 18 observational studies, 58 case reports and 2 economic studies after the screening process. The included SRs enrolled patients with pediatric epilepsy, epilepsy in pregnancy, focal epilepsy, generalized epilepsy and refractory focal epilepsy. Meta-analysis of the included RCTs indicated that LEV was as effective as carbamazepine (CBZ; treatment for 6 months: 58.9% vs 64.8%, OR=0.76, 95% CI: 0.50-1.16; 12 months: 54.9% vs 55.5%, OR=1.24, 95% CI: 0.79-1.93), oxcarbazepine (57.7% vs 59.8%, OR=1.34, 95% CI: 0.34-5.23), phenobarbital (50.0% vs 50.9%, OR=1.20, 95% CI: 0.51-2.82) and lamotrigine (LTG; 61.5% vs 57.7%, OR=1.22, 95% CI: 0.90-1.66). SRs and observational studies indicated a low malformation rate and intrauterine death rate for pregnant women, as well as low risk of cognitive side effects. But psychiatric and behavioral side effects could not be ruled out. LEV decreased discontinuation due to adverse events compared with CBZ (OR=0.52, 95% CI: 0.41-0.65), while no difference was found when LEV was compared with placebo and LTG. Two cost-effectiveness evaluations for refractory epilepsy with decision-tree model showed US$ 76.18 per seizure-free day gained in Canada and US$ 44 per seizure-free day gained in Korea. CONCLUSION LEV is as effective as CBZ, oxcarbazepine, phenobarbital and LTG and has an advantage for pregnant women and in cognitive functions. Limited evidence supports its cost-effectiveness. REGISTERED NUMBER PROSPERO (No CRD 42017069367).
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Affiliation(s)
- Zhan-Miao Yi
- Department of Pharmacy, Peking University Third Hospital, Beijing, China,
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- Department of Pharmacy, Peking University Third Hospital, Beijing, China,
| | - Cheng Wen
- Department of Pharmacy, Peking University Third Hospital, Beijing, China,
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University Health Science Center, Beijing, China
| | - Ting Cai
- Department of Epidemiology and Bio-statistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Lu Xu
- Department of Epidemiology and Bio-statistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Xu-Li Zhong
- Department of Pharmacy, Children's Hospital Affiliated to Capital Institute of Pediatrics, Beijing, China
| | - Si-Yan Zhan
- Department of Epidemiology and Bio-statistics, School of Public Health, Peking University Health Science Center, Beijing, China
- Center for Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Suo-Di Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China,
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China,
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9
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Sivathamboo S, Perucca P, Velakoulis D, Jones NC, Goldin J, Kwan P, O’Brien TJ. Sleep-disordered breathing in epilepsy: epidemiology, mechanisms, and treatment. Sleep 2018; 41:4830560. [DOI: 10.1093/sleep/zsy015] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Shobi Sivathamboo
- Department of Medicine, University of Melbourne, Victoria, Australia
- Department of Neurology, Royal Melbourne Hospital, Victoria, Australia
| | - Piero Perucca
- Department of Medicine, University of Melbourne, Victoria, Australia
- Department of Neurology, Royal Melbourne Hospital, Victoria, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Dennis Velakoulis
- Department of Psychiatry, Neuropsychiatry Unit, Royal Melbourne Hospital, Victoria, Australia
| | - Nigel C Jones
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Jeremy Goldin
- Department of Respiratory and Sleep Disorders Medicine, Royal Melbourne Hospital, Victoria, Australia
| | - Patrick Kwan
- Department of Medicine, University of Melbourne, Victoria, Australia
- Department of Neurology, Royal Melbourne Hospital, Victoria, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Terence J O’Brien
- Department of Medicine, University of Melbourne, Victoria, Australia
- Department of Neurology, Royal Melbourne Hospital, Victoria, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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10
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Fureman BE, Friedman D, Baulac M, Glauser T, Moreno J, Dixon-Salazar T, Bagiella E, Connor J, Ferry J, Farrell K, Fountain NB, French JA. Reducing placebo exposure in trials: Considerations from the Research Roundtable in Epilepsy. Neurology 2017; 89:1507-1515. [PMID: 28878049 DOI: 10.1212/wnl.0000000000004535] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 07/10/2017] [Indexed: 11/15/2022] Open
Abstract
The randomized controlled trial is the unequivocal gold standard for demonstrating clinical efficacy and safety of investigational therapies. Recently there have been concerns raised about prolonged exposure to placebo and ineffective therapy during the course of an add-on regulatory trial for new antiepileptic drug approval (typically ∼6 months in duration), due to the potential risks of continued uncontrolled epilepsy for that period. The first meeting of the Research Roundtable in Epilepsy on May 19-20, 2016, focused on "Reducing placebo exposure in epilepsy clinical trials," with a goal of considering new designs for epilepsy regulatory trials that may be added to the overall development plan to make it, as a whole, safer for participants while still providing rigorous evidence of effect. This topic was motivated in part by data from a meta-analysis showing a 3- to 5-fold increased rate of sudden unexpected death in epilepsy in participants randomized to placebo or ineffective doses of new antiepileptic drugs. The meeting agenda included rationale and discussion of different trial designs, including active-control add-on trials, placebo add-on to background therapy with adjustment, time to event designs, adaptive designs, platform trials with pooled placebo control, a pharmacokinetic/pharmacodynamic approach to reducing placebo exposure, and shorter trials when drug tolerance has been ruled out. The merits and limitations of each design were discussed and are reviewed here.
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Affiliation(s)
- Brandy E Fureman
- From the Research and New Therapies Program (B.E.F., K.F., J.A.F.), Epilepsy Foundation of America, Landover, MD; Department of Neurology (D.F., J.A.F.), New York University, New York; Department of Neurology (M.B.), Hôpital la Salpêtrière, APHP/ICM, University Pierre et Marie Curie, Paris, France; Cincinnati Children's Research Foundation (T.G.), OH; University of Pennsylvania (J.M.), Philadelphia; LGS Foundation (Lennox-Gastaut Syndrome) (T.D.-S.), Bohemia; Mount Sinai School of Medicine (E.B.), New York, NY; Berry Consultants LLC and University of Central Florida College of Medicine (J.C.), Orlando; Eisai Inc. (J.F.), Woodcliff Lake, NJ; and Department of Neurology (N.B.F.), University of Virginia, Charlottesville.
| | - Daniel Friedman
- From the Research and New Therapies Program (B.E.F., K.F., J.A.F.), Epilepsy Foundation of America, Landover, MD; Department of Neurology (D.F., J.A.F.), New York University, New York; Department of Neurology (M.B.), Hôpital la Salpêtrière, APHP/ICM, University Pierre et Marie Curie, Paris, France; Cincinnati Children's Research Foundation (T.G.), OH; University of Pennsylvania (J.M.), Philadelphia; LGS Foundation (Lennox-Gastaut Syndrome) (T.D.-S.), Bohemia; Mount Sinai School of Medicine (E.B.), New York, NY; Berry Consultants LLC and University of Central Florida College of Medicine (J.C.), Orlando; Eisai Inc. (J.F.), Woodcliff Lake, NJ; and Department of Neurology (N.B.F.), University of Virginia, Charlottesville
| | - Michel Baulac
- From the Research and New Therapies Program (B.E.F., K.F., J.A.F.), Epilepsy Foundation of America, Landover, MD; Department of Neurology (D.F., J.A.F.), New York University, New York; Department of Neurology (M.B.), Hôpital la Salpêtrière, APHP/ICM, University Pierre et Marie Curie, Paris, France; Cincinnati Children's Research Foundation (T.G.), OH; University of Pennsylvania (J.M.), Philadelphia; LGS Foundation (Lennox-Gastaut Syndrome) (T.D.-S.), Bohemia; Mount Sinai School of Medicine (E.B.), New York, NY; Berry Consultants LLC and University of Central Florida College of Medicine (J.C.), Orlando; Eisai Inc. (J.F.), Woodcliff Lake, NJ; and Department of Neurology (N.B.F.), University of Virginia, Charlottesville
| | - Tracy Glauser
- From the Research and New Therapies Program (B.E.F., K.F., J.A.F.), Epilepsy Foundation of America, Landover, MD; Department of Neurology (D.F., J.A.F.), New York University, New York; Department of Neurology (M.B.), Hôpital la Salpêtrière, APHP/ICM, University Pierre et Marie Curie, Paris, France; Cincinnati Children's Research Foundation (T.G.), OH; University of Pennsylvania (J.M.), Philadelphia; LGS Foundation (Lennox-Gastaut Syndrome) (T.D.-S.), Bohemia; Mount Sinai School of Medicine (E.B.), New York, NY; Berry Consultants LLC and University of Central Florida College of Medicine (J.C.), Orlando; Eisai Inc. (J.F.), Woodcliff Lake, NJ; and Department of Neurology (N.B.F.), University of Virginia, Charlottesville
| | - Jonathan Moreno
- From the Research and New Therapies Program (B.E.F., K.F., J.A.F.), Epilepsy Foundation of America, Landover, MD; Department of Neurology (D.F., J.A.F.), New York University, New York; Department of Neurology (M.B.), Hôpital la Salpêtrière, APHP/ICM, University Pierre et Marie Curie, Paris, France; Cincinnati Children's Research Foundation (T.G.), OH; University of Pennsylvania (J.M.), Philadelphia; LGS Foundation (Lennox-Gastaut Syndrome) (T.D.-S.), Bohemia; Mount Sinai School of Medicine (E.B.), New York, NY; Berry Consultants LLC and University of Central Florida College of Medicine (J.C.), Orlando; Eisai Inc. (J.F.), Woodcliff Lake, NJ; and Department of Neurology (N.B.F.), University of Virginia, Charlottesville
| | - Tracy Dixon-Salazar
- From the Research and New Therapies Program (B.E.F., K.F., J.A.F.), Epilepsy Foundation of America, Landover, MD; Department of Neurology (D.F., J.A.F.), New York University, New York; Department of Neurology (M.B.), Hôpital la Salpêtrière, APHP/ICM, University Pierre et Marie Curie, Paris, France; Cincinnati Children's Research Foundation (T.G.), OH; University of Pennsylvania (J.M.), Philadelphia; LGS Foundation (Lennox-Gastaut Syndrome) (T.D.-S.), Bohemia; Mount Sinai School of Medicine (E.B.), New York, NY; Berry Consultants LLC and University of Central Florida College of Medicine (J.C.), Orlando; Eisai Inc. (J.F.), Woodcliff Lake, NJ; and Department of Neurology (N.B.F.), University of Virginia, Charlottesville
| | - Emilia Bagiella
- From the Research and New Therapies Program (B.E.F., K.F., J.A.F.), Epilepsy Foundation of America, Landover, MD; Department of Neurology (D.F., J.A.F.), New York University, New York; Department of Neurology (M.B.), Hôpital la Salpêtrière, APHP/ICM, University Pierre et Marie Curie, Paris, France; Cincinnati Children's Research Foundation (T.G.), OH; University of Pennsylvania (J.M.), Philadelphia; LGS Foundation (Lennox-Gastaut Syndrome) (T.D.-S.), Bohemia; Mount Sinai School of Medicine (E.B.), New York, NY; Berry Consultants LLC and University of Central Florida College of Medicine (J.C.), Orlando; Eisai Inc. (J.F.), Woodcliff Lake, NJ; and Department of Neurology (N.B.F.), University of Virginia, Charlottesville
| | - Jason Connor
- From the Research and New Therapies Program (B.E.F., K.F., J.A.F.), Epilepsy Foundation of America, Landover, MD; Department of Neurology (D.F., J.A.F.), New York University, New York; Department of Neurology (M.B.), Hôpital la Salpêtrière, APHP/ICM, University Pierre et Marie Curie, Paris, France; Cincinnati Children's Research Foundation (T.G.), OH; University of Pennsylvania (J.M.), Philadelphia; LGS Foundation (Lennox-Gastaut Syndrome) (T.D.-S.), Bohemia; Mount Sinai School of Medicine (E.B.), New York, NY; Berry Consultants LLC and University of Central Florida College of Medicine (J.C.), Orlando; Eisai Inc. (J.F.), Woodcliff Lake, NJ; and Department of Neurology (N.B.F.), University of Virginia, Charlottesville
| | - Jim Ferry
- From the Research and New Therapies Program (B.E.F., K.F., J.A.F.), Epilepsy Foundation of America, Landover, MD; Department of Neurology (D.F., J.A.F.), New York University, New York; Department of Neurology (M.B.), Hôpital la Salpêtrière, APHP/ICM, University Pierre et Marie Curie, Paris, France; Cincinnati Children's Research Foundation (T.G.), OH; University of Pennsylvania (J.M.), Philadelphia; LGS Foundation (Lennox-Gastaut Syndrome) (T.D.-S.), Bohemia; Mount Sinai School of Medicine (E.B.), New York, NY; Berry Consultants LLC and University of Central Florida College of Medicine (J.C.), Orlando; Eisai Inc. (J.F.), Woodcliff Lake, NJ; and Department of Neurology (N.B.F.), University of Virginia, Charlottesville
| | - Kathleen Farrell
- From the Research and New Therapies Program (B.E.F., K.F., J.A.F.), Epilepsy Foundation of America, Landover, MD; Department of Neurology (D.F., J.A.F.), New York University, New York; Department of Neurology (M.B.), Hôpital la Salpêtrière, APHP/ICM, University Pierre et Marie Curie, Paris, France; Cincinnati Children's Research Foundation (T.G.), OH; University of Pennsylvania (J.M.), Philadelphia; LGS Foundation (Lennox-Gastaut Syndrome) (T.D.-S.), Bohemia; Mount Sinai School of Medicine (E.B.), New York, NY; Berry Consultants LLC and University of Central Florida College of Medicine (J.C.), Orlando; Eisai Inc. (J.F.), Woodcliff Lake, NJ; and Department of Neurology (N.B.F.), University of Virginia, Charlottesville
| | - Nathan B Fountain
- From the Research and New Therapies Program (B.E.F., K.F., J.A.F.), Epilepsy Foundation of America, Landover, MD; Department of Neurology (D.F., J.A.F.), New York University, New York; Department of Neurology (M.B.), Hôpital la Salpêtrière, APHP/ICM, University Pierre et Marie Curie, Paris, France; Cincinnati Children's Research Foundation (T.G.), OH; University of Pennsylvania (J.M.), Philadelphia; LGS Foundation (Lennox-Gastaut Syndrome) (T.D.-S.), Bohemia; Mount Sinai School of Medicine (E.B.), New York, NY; Berry Consultants LLC and University of Central Florida College of Medicine (J.C.), Orlando; Eisai Inc. (J.F.), Woodcliff Lake, NJ; and Department of Neurology (N.B.F.), University of Virginia, Charlottesville
| | - Jacqueline A French
- From the Research and New Therapies Program (B.E.F., K.F., J.A.F.), Epilepsy Foundation of America, Landover, MD; Department of Neurology (D.F., J.A.F.), New York University, New York; Department of Neurology (M.B.), Hôpital la Salpêtrière, APHP/ICM, University Pierre et Marie Curie, Paris, France; Cincinnati Children's Research Foundation (T.G.), OH; University of Pennsylvania (J.M.), Philadelphia; LGS Foundation (Lennox-Gastaut Syndrome) (T.D.-S.), Bohemia; Mount Sinai School of Medicine (E.B.), New York, NY; Berry Consultants LLC and University of Central Florida College of Medicine (J.C.), Orlando; Eisai Inc. (J.F.), Woodcliff Lake, NJ; and Department of Neurology (N.B.F.), University of Virginia, Charlottesville
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11
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Zhao T, Feng X, Liu J, Gao J, Zhou C. Evaluate the Efficacy and Safety of Anti-Epileptic Medications for Partial Seizures of Epilepsy: A Network Meta-Analysis. J Cell Biochem 2017; 118:2850-2864. [PMID: 28214290 DOI: 10.1002/jcb.25936] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 02/16/2017] [Indexed: 12/15/2022]
Affiliation(s)
- Teng Zhao
- Department of Neurology; The First Teaching Hospital of Jilin University; Changchun Jilin 130021 China
| | - Xuemin Feng
- Department of Neurology; The First Teaching Hospital of Jilin University; Changchun Jilin 130021 China
| | - Jingyao Liu
- Department of Neurology; The First Teaching Hospital of Jilin University; Changchun Jilin 130021 China
| | - Jiguo Gao
- Department of Neurology; The First Teaching Hospital of Jilin University; Changchun Jilin 130021 China
| | - Chunkui Zhou
- Department of Neurology; The First Teaching Hospital of Jilin University; Changchun Jilin 130021 China
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12
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Response to “Response to Zhang et al.: Levetiracetam vs. brivaracetam for adults with refractory focal seizures: A meta-analysis and indirect comparison”. Seizure 2016; 41:184-6. [DOI: 10.1016/j.seizure.2016.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 08/01/2016] [Indexed: 11/24/2022] Open
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13
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French J, Glue P, Friedman D, Almas M, Yardi N, Knapp L, Pitman V, Posner HB. Adjunctive pregabalin vs gabapentin for focal seizures: Interpretation of comparative outcomes. Neurology 2016; 87:1242-9. [PMID: 27521437 PMCID: PMC5035985 DOI: 10.1212/wnl.0000000000003118] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 06/07/2016] [Indexed: 11/17/2022] Open
Abstract
Objective: To evaluate the comparative safety and adjunctive efficacy of pregabalin and gabapentin in reducing seizure frequency in patients with partial-onset seizures based on prestudy modeling showing superior efficacy for pregabalin. Methods: The design of this comparative efficacy and safety study of pregabalin and gabapentin as adjunctive treatment in adults with refractory partial-onset seizures was randomized, flexible dose, double blind, and parallel group. The study included a 6-week baseline and a 21-week treatment phase. The primary endpoint was the percentage change from baseline in 28-day seizure rate to the treatment phase. Results: A total of 484 patients were randomized to pregabalin (n = 242) or gabapentin (n = 242). Of these, 359 patients (187 pregabalin, 172 gabapentin) completed the treatment phase. The observed median and mean in percentage change from baseline was −58.65 and −47.7 (SD 48.3) for pregabalin and −57.43 and −45.28 (SD 60.6) for gabapentin. For the primary endpoint, there was no significant difference between treatments. The Hodges-Lehman estimated median difference was 0.0 (95% confidence interval −6.0 to 7.0). Safety profiles were comparable and consistent with prior trials. Conclusions: The absence of the anticipated efficacy difference based on modeling of prior, nearly identical trials and the larger-than-expected response rates of the 2 antiepileptic drugs were unexpected. These findings raise questions that are potentially important to consider in future comparative efficacy trials. ClinicalTrials.gov identifier: NCT00537940. Classification of evidence: This study provides Class II evidence that for patients with partial seizures enrolled in this study, pregabalin is not superior to gabapentin in reducing seizure frequency. Because of the atypical response rates, the results of this study are poorly generalizable to other epilepsy populations.
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Affiliation(s)
- Jacqueline French
- From the NYU Comprehensive Epilepsy Center (J.F., D.F.), New York, NY; Department of Psychological Medicine, Dunedin School of Medicine, University of Otago (P.G.), New Zealand; Global Product Development, Pfizer Inc. (M.A., H.B.P.), New York, NY; Yardi Epilepsy Clinic, KEM and Vatsal Hospital (N.Y.), Pune, India; and Global Product Development, Pfizer Inc. (L.K., V.P.), Groton, CT.
| | - Paul Glue
- From the NYU Comprehensive Epilepsy Center (J.F., D.F.), New York, NY; Department of Psychological Medicine, Dunedin School of Medicine, University of Otago (P.G.), New Zealand; Global Product Development, Pfizer Inc. (M.A., H.B.P.), New York, NY; Yardi Epilepsy Clinic, KEM and Vatsal Hospital (N.Y.), Pune, India; and Global Product Development, Pfizer Inc. (L.K., V.P.), Groton, CT
| | - Daniel Friedman
- From the NYU Comprehensive Epilepsy Center (J.F., D.F.), New York, NY; Department of Psychological Medicine, Dunedin School of Medicine, University of Otago (P.G.), New Zealand; Global Product Development, Pfizer Inc. (M.A., H.B.P.), New York, NY; Yardi Epilepsy Clinic, KEM and Vatsal Hospital (N.Y.), Pune, India; and Global Product Development, Pfizer Inc. (L.K., V.P.), Groton, CT
| | - Mary Almas
- From the NYU Comprehensive Epilepsy Center (J.F., D.F.), New York, NY; Department of Psychological Medicine, Dunedin School of Medicine, University of Otago (P.G.), New Zealand; Global Product Development, Pfizer Inc. (M.A., H.B.P.), New York, NY; Yardi Epilepsy Clinic, KEM and Vatsal Hospital (N.Y.), Pune, India; and Global Product Development, Pfizer Inc. (L.K., V.P.), Groton, CT
| | - Nandan Yardi
- From the NYU Comprehensive Epilepsy Center (J.F., D.F.), New York, NY; Department of Psychological Medicine, Dunedin School of Medicine, University of Otago (P.G.), New Zealand; Global Product Development, Pfizer Inc. (M.A., H.B.P.), New York, NY; Yardi Epilepsy Clinic, KEM and Vatsal Hospital (N.Y.), Pune, India; and Global Product Development, Pfizer Inc. (L.K., V.P.), Groton, CT
| | - Lloyd Knapp
- From the NYU Comprehensive Epilepsy Center (J.F., D.F.), New York, NY; Department of Psychological Medicine, Dunedin School of Medicine, University of Otago (P.G.), New Zealand; Global Product Development, Pfizer Inc. (M.A., H.B.P.), New York, NY; Yardi Epilepsy Clinic, KEM and Vatsal Hospital (N.Y.), Pune, India; and Global Product Development, Pfizer Inc. (L.K., V.P.), Groton, CT
| | - Verne Pitman
- From the NYU Comprehensive Epilepsy Center (J.F., D.F.), New York, NY; Department of Psychological Medicine, Dunedin School of Medicine, University of Otago (P.G.), New Zealand; Global Product Development, Pfizer Inc. (M.A., H.B.P.), New York, NY; Yardi Epilepsy Clinic, KEM and Vatsal Hospital (N.Y.), Pune, India; and Global Product Development, Pfizer Inc. (L.K., V.P.), Groton, CT
| | - Holly B Posner
- From the NYU Comprehensive Epilepsy Center (J.F., D.F.), New York, NY; Department of Psychological Medicine, Dunedin School of Medicine, University of Otago (P.G.), New Zealand; Global Product Development, Pfizer Inc. (M.A., H.B.P.), New York, NY; Yardi Epilepsy Clinic, KEM and Vatsal Hospital (N.Y.), Pune, India; and Global Product Development, Pfizer Inc. (L.K., V.P.), Groton, CT
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14
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Perucca E, Wiebe S. Not all that glitters is gold: A guide to the critical interpretation of drug trials in epilepsy. Epilepsia Open 2016; 1:9-21. [PMID: 29588925 PMCID: PMC5867835 DOI: 10.1002/epi4.3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2016] [Indexed: 01/10/2023] Open
Abstract
Clinical trials represent the best source of evidence on which to base treatment decisions. For such evidence to be utilized meaningfully, however, it is essential that results are interpreted correctly. This requires a good understanding of strengths and weaknesses of the adopted design, the clinical relevance of the outcome measures, and the many factors that could affect such outcomes. As a general rule, uncontrolled studies tend to provide misleading evidence as a result of the impact of confounders such as regression to the mean, patient‐related bias, and observer bias. On the other hand, although randomized controlled trials (RCTs) are qualitatively superior, aspects of their execution may still decrease their validity. Bias and decreased validity in RCTs may occur by chance alone (for example, treatment groups may not necessarily be balanced for important variables despite randomization) or because of specific features of the trial design. In the case of industry‐driven studies, bias often influences the outcome in favor of the sponsor's product. Factors that need to be carefully scrutinized include (1) the purpose for which the trial is conducted; (2) potential bias due to unblinding or lack of blinding; (3) the appropriateness of the control group; (4) the power of the study in detecting clinically relevant differences; (5) the extent to which eligibility criteria could affect outcomes and be representative of routine clinical practice; (6) whether the treatments being compared are used optimally in terms of dosing, duration of treatment, and other variables; (7) the appropriateness of the statistical comparisons; (8) the clinical relevance of the outcome measures and whether all key outcome information is reported (for example, responder rates in completers); and (9) potential bias in the way results are presented and discussed. This article discusses each of these aspects and illustrates the discussion with examples taken from published antiepileptic drug trials.
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Affiliation(s)
- Emilio Perucca
- C. Mondino National Neurological Institute Pavia Italy.,Division of Clinical and Experimental Pharmacology Department of Internal Medicine and Therapeutics University of Pavia Pavia Italy
| | - Samuel Wiebe
- Department of Clinical Neurosciences and Hotchkiss Brain Institute Cumming School of Medicine University of Calgary Calgary Alberta Canada.,Department of Community Health Sciences and O'Brien Institute for Public Health Cumming School of Medicine University of Calgary Calgary Alberta Canada
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15
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Beran RG, Stepanova D, Beran ME. Justification for conducting neurological clinical trials as part of patient care within private practice. Int J Clin Pract 2016; 70:365-71. [PMID: 27040457 DOI: 10.1111/ijcp.12800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The aim of this review was to assess the benefits and drawbacks of conducting neurological clinical trials and research in private practice for the patients, clinician, Practice Manager, sponsors/Clinical Research Organisations (CROs) and Clinical Trial Coordinator (CTC) to determine if this is justified for all involved. A combination of literature reviews, original research articles and books were selected from 2005 to 2015. Provided that the practice has sufficient number of active trials to prevent financial loss, support staff, adequate facilities and equipment and time, the benefits outweigh the drawbacks. Clinical trials provide patients with more thorough monitoring, re-imbursement of trial-related expenses and the opportunity to try an innovative treatment at no charge when other options have failed. For the clinician, clinical trials provide more information to ensure better care for their patients and improved treatment methods, technical experience and global recognition. Trials collect detailed and up-to-date information on the benefits and risks of drugs, improving society's confidence in clinical research and pharmaceuticals, allow trial sponsors to explore new scientific questions and accelerate innovation. For the CTC, industry-sponsored clinical trials allow potential entry for a career in clinical research giving CTCs the opportunity to become Clinical Research Associates (CRAs), Study Start-Up Managers or Drug Safety Associates.
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Affiliation(s)
- R G Beran
- Liverpool Hospital, Sydney, NSW, Australia
- Griffith University, Gold Coast and Brisbane, Qld, Australia
- Strategic Health Evaluators, Sydney, NSW, Australia
| | - D Stepanova
- Strategic Health Evaluators, Sydney, NSW, Australia
| | - M E Beran
- Strategic Health Evaluators, Sydney, NSW, Australia
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16
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Verrotti A, Prezioso G, Di Sabatino F, Franco V, Chiarelli F, Zaccara G. The adverse event profile of levetiracetam: A meta-analysis on children and adults. Seizure 2015; 31:49-55. [DOI: 10.1016/j.seizure.2015.07.004] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 07/05/2015] [Accepted: 07/07/2015] [Indexed: 10/23/2022] Open
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17
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Beltramini GC, Cendes F, Yasuda CL. The effects of antiepileptic drugs on cognitive functional magnetic resonance imaging. Quant Imaging Med Surg 2015; 5:238-46. [PMID: 25853082 DOI: 10.3978/j.issn.2223-4292.2015.01.04] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 01/22/2015] [Indexed: 12/15/2022]
Abstract
The cognitive dysfunction caused by antiepileptic drugs (AEDs) has been extensively described, although the mechanisms underlying such collateral effects are still poorly understood. The combination of functional magnetic resonance imaging (fMRI) studies with pharmacological intervention (pharmaco-MRI or ph-MRI) offers the opportunity to investigate the effect of drugs such as AEDs on brain activity, including cognitive tasks. Here we review the studies that investigated the effects of AEDs [topiramate (TPM), lamotrigine (LMT), carbamazepine (CBZ), pregabalin (PGB), valproate (VPA) and levetiracetam (LEV)] on cognitive fMRI tasks. Despite the scarcity of fMRI studies focusing on the impact of AEDs on cognitive task, the results of recent work have provided important information about specific drug-related changes of brain function.
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Affiliation(s)
| | - Fernando Cendes
- Laboratory of Neuroimaging, Department of Neurology, University of Campinas, Campinas, SP, Brazil
| | - Clarissa Lin Yasuda
- Laboratory of Neuroimaging, Department of Neurology, University of Campinas, Campinas, SP, Brazil
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