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Silvinato A, Floriano I, Bernardo WM. Use of cannabidiol in the treatment of epilepsy: Lennox-Gastaut syndrome, Dravet syndrome, and tuberous sclerosis complex. Rev Assoc Med Bras (1992) 2022; 68:1345-1357. [PMID: 36417631 PMCID: PMC9683917 DOI: 10.1590/1806-9282.2022d689] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The objective of this systematic review with meta-analysis was to evaluate the efficacy, safety, and short- and long-term tolerability of cannabidiol (CBD), as an adjunct treatment, in children and adults with Dravet syndrome (SD), Lennox-Gataut syndrome (LGS), or tuberous sclerosis complex (TSC), with inadequate control of seizures. METHODS This systematic review was conducted through a search for scientific evidence in the Mediline/PubMed, Central Cochrane, and ClinicalTrials.gov databases until April 2022. Selected randomized clinical trials (RCTs) that presented the outcomes: reduction in the frequency of seizures and total seizures (all types), number of patients with a response greater than or equal to 50%, change in caregiver global impression of change (CGIC) (improvement ≥1 category on the initial scale), adverse events (AEs), and tolerability to treatment. This review followed Preferred Reporting Items for Systematic reviews and Meta-Analyses. RESULTS Notably, six RCTs were included, with a total of 1,034 patients with SD, LGS, and TSC, of which 3 were open-label extension RCTs. The meta-analysis of the studies showed that the use of CBD as compared with placebo, in patients with convulsive seizures refractory to the use of medications, reduces the frequency of seizures by 33%; increases the number of patients with a reduction ≥50% in the frequency of seizures by 20%; increases the number of patients with absence of seizures by 3%; improves the clinical impression evaluated by the caregiver or patient (S/CGIC) in 21%; increases total AEs by 12%; increases serious AE by 16%; increases the risk of treatment abandonment by 12%; and increases the number of patients with transaminase elevation (≥3 times the referral) by 15%. CONCLUSIONS This systematic review, with meta-analysis, supports the use of CBD in the treatment of patients with seizures, originated in DS, LGS, and TSC, who are resistant to the common medications, presenting satisfactory benefits in reducing seizures and tolerable toxicity.
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Na JH, Jung DE, Kang HJ, Kang HC, Kim HD. Treatment strategies for Lennox-Gastaut syndrome: outcomes of multimodal treatment approaches. Ther Adv Neurol Disord 2022; 15:17562864221108012. [PMID: 35958038 PMCID: PMC9358332 DOI: 10.1177/17562864221108012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 05/31/2022] [Indexed: 11/16/2022] Open
Abstract
Background Multimodal treatment approaches are often considered for patients with Lennox-Gastaut syndrome (LGS). Creating an algorithm that can guide healthcare providers in selecting treatment options for patients with LGS remains a challenge. Herein, we assessed the long-term seizure-free and neurodevelopmental outcomes of stepwise multimodal treatment in patients with LGS. Objective Herein, we assess the long-term seizure-free and neurodevelopmental outcomes of stepwise multimodal treatment in patients with LGS. Methods We retrospectively examined the data of 371 patients with LGS who underwent stepwise multimodal treatment, including antiseizure medication (ASM) therapy, dietary therapy (DT), resective epilepsy surgery (R-ES), and palliative epilepsy surgery (P-ES). The seizure-free outcome was considered to be the effect of the final treatment according to the treatment algorithm, and the percentage of patients who remained seizure-free in each treatment group was calculated. ASM treatment, DT, R-ES, and P-ES were applied to 371 (100%), 201 (54.2%), 112 (30.2%), and 115 (31.0%) patients with LGS, respectively. We evaluated the stepwise multimodal treatment outcomes in these patients. Results One hundred sixty-eight patients (45.3%) remained seizure-free for at least 1 year (seizure-free-for-1-year group), 61 of whom (16.5%) remained seizure-free for more than 5 years (remained-seizure-free group). Among the patients treated with ASM therapy, DT, R-ES, and P-ES, 41 (11.1%), 53 (14.3%), 56 (15.1%), and 29 (7.8%), respectively, remained seizure-free for 1 year. In addition, 15 (4.1%), 15 (4.1%), 19 (5.1%), and 12 (3.2%) patients in the ASM, DT, R-ES, and P-ES treatment groups, respectively, remained seizure-free for more than 5 years. Both the seizure-free-for-1-year and remained-seizure-free groups showed significant improvement in electroencephalography findings and neurodevelopmental status following treatment. Conclusion This study provides an update on the long-term seizure outcomes and neurodevelopmental improvements in a large cohort of patients with LGS following comprehensive multimodal treatment. We emphasize that the active combination of multiple ASMs, DT, and surgical treatment could provide long-term seizure-free outcomes and significant neurological benefits to patients with LGS.
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Affiliation(s)
- Ji-Hoon Na
- Division of Pediatric Neurology, Department of Pediatrics, Epilepsy Research Institute, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Da Eun Jung
- Department of Pediatrics, Ajou Hospital, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Hee Jung Kang
- Division of Pediatric Neurology, Department of Pediatrics, Epilepsy Research Institute, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hoon-Chul Kang
- Division of Pediatric Neurology, Department of Pediatrics, Epilepsy Research Institute, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Heung Dong Kim
- Division of Pediatric Neurology, Department of Pediatrics, Epilepsy Research Institute, Severance Children's Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
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Yang D, Na JH, Kim SH, Kim HD, Lee JS, Kang HC. Efficacy and prognosis of long-term, high-dose steroid therapy for Lennox-Gastaut syndrome. Epilepsy Res 2022; 179:106847. [PMID: 34979339 DOI: 10.1016/j.eplepsyres.2021.106847] [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: 09/03/2021] [Revised: 12/15/2021] [Accepted: 12/23/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Lennox-Gastaut syndrome (LGS) is a severe form of developmental and epileptic encephalopathy that is highly resistant to treatment with conventional anti-epileptic drugs and non-pharmacological therapies. In the present study, we aimed to investigate the efficacy of long-term, high-dose steroid therapy and its effect on prognosis in children with LGS. METHODS This prospective study included patients with LGS who received long-term, high-dose steroid therapy beginning in November 2016. Prednisolone (60 mg per day) was administered for 2 weeks, following which the dosage was reduced to 60 mg on alternate days for 12 weeks. The drug was then slowly tapered over the next 3 months. The primary outcome was a reduction in seizure frequency relative to baseline at 14 weeks. The secondary outcome was whether patients had become seizure-free at 1 year. RESULTS Among 44 patients, 30 (68.2%) experienced a reduction in seizure frequency of more than 50%, including 26 (59.1%) with complete seizure control who were classified as the responder group. The remaining 14 (31.8%) were classified as the non-responder group after 14 weeks of treatment. Twenty patients (45.5%, 20/44) remained seizure-free after 1 year of treatment. However, 10 patients (33.3%, 10/30) in the responder group relapsed within a year. Improvements in electroencephalography (EEG) findings tended to be consistent with seizure outcomes. All patients had side effects of weight gain and Cushing's face, but most adverse effects were mild and transient. CONCLUSION Long-term, high-dose steroid therapy can be considered an effective treatment option for children with intractable LGS.
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Affiliation(s)
- Donghwa Yang
- Divison of Pediatric Neurology, Department of Pediatrics, National Health Insurance Service Ilsan Hospital, Goyang-si, Gyunggi-do, Republic of Korea; Divison of Pediatric Neurology, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Epilepsy Research Institute, Seoul, Republic of Korea
| | - Ji-Hoon Na
- Divison of Pediatric Neurology, Department of Pediatrics, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Se Hee Kim
- Divison of Pediatric Neurology, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Epilepsy Research Institute, Seoul, Republic of Korea
| | - Heung Dong Kim
- Divison of Pediatric Neurology, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Epilepsy Research Institute, Seoul, Republic of Korea
| | - Joon Soo Lee
- Divison of Pediatric Neurology, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Epilepsy Research Institute, Seoul, Republic of Korea
| | - Hoon-Chul Kang
- Divison of Pediatric Neurology, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Epilepsy Research Institute, Seoul, Republic of Korea.
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Lin YC, Lai YC, Chou P, Hsueh SW, Lin TH, Huang CS, Wang RW, Yang YC, Kuo CC. How Can an Na + Channel Inhibitor Ameliorate Seizures in Lennox-Gastaut Syndrome? Ann Neurol 2021; 89:1099-1113. [PMID: 33745195 DOI: 10.1002/ana.26068] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 02/23/2021] [Accepted: 03/14/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Lennox-Gastaut syndrome (LGS) is an epileptic encephalopathy frequently associated with multiple types of seizures. The classical Na+ channel inhibitors are in general ineffective against the seizures in LGS. Rufinamide is a new Na+ channel inhibitor, but approved for the treatment of LGS. This is not consistent with a choice of antiseizure drugs (ASDs) according to simplistic categorical grouping. METHODS The effect of rufinamide on the Na+ channel, cellular discharges, and seizure behaviors was quantitatively characterized in native neurons and mammalian models of epilepsy, and compared with the other Na+ channel inhibitors. RESULTS With a much faster binding rate to the inactivated Na+ channel than phenytoin, rufinamide is distinctively effective if the seizure discharges chiefly involve short bursts interspersed with hyperpolarized interburst intervals, exemplified by spike and wave discharges (SWDs) on electroencephalograms. Consistently, rufinamide, but not phenytoin, suppresses SWD-associated seizures in pentylenetetrazol or AY-9944 models, which recapitulate the major electrophysiological and behavioral manifestations in typical and atypical absence seizures, including LGS. INTERPRETATION Na+ channel inhibitors shall have sufficiently fast binding to exert an action during the short bursts and then suppress SWDs, in which cases rufinamide is superior. For the epileptiform discharges where the interburst intervals are not so hyperpolarized, phenytoin could be better because of the higher affinity. Na+ channel inhibitors with different binding kinetics and affinity to the inactivated channels may have different antiseizure scope. A rational choice of ASDs according to in-depth molecular pharmacology and the attributes of ictal discharges is advisable. ANN NEUROL 2021;89:1099-1113.
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Affiliation(s)
- Yun-Chu Lin
- Department of Physiology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yi-Chen Lai
- Department of Biomedical Sciences, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Ping Chou
- Department of Physiology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shu-Wei Hsueh
- Department of Biomedical Sciences, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan.,Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Tien-Hung Lin
- Department of Physiology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chen-Syuan Huang
- Department of Biomedical Sciences, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan.,Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Ren-Wei Wang
- Department of Physiology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ya-Chin Yang
- Department of Biomedical Sciences, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan.,Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan.,Neuroscience Research Center, Chang Gung Memorial Hospital, Linkou Medical Center, Tao-Yuan, Taiwan
| | - Chung-Chin Kuo
- Department of Physiology, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
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Gunning B, Mazurkiewicz‐Bełdzińska M, Chin RFM, Bhathal H, Nortvedt C, Dunayevich E, Checketts D. Cannabidiol in conjunction with clobazam: analysis of four randomized controlled trials. Acta Neurol Scand 2021; 143:154-163. [PMID: 32969022 PMCID: PMC7821324 DOI: 10.1111/ane.13351] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/03/2020] [Accepted: 09/14/2020] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To assess the efficacy and safety profile of add-on cannabidiol (CBD) in patients with Lennox-Gastaut syndrome (LGS) and Dravet syndrome (DS) on clobazam and in the overall population of four randomized, controlled phase 3 trials. METHODS Patients received plant-derived, highly purified CBD medicine (Epidiolex® in the USA; Epidyolex® in Europe; 100 mg/ml oral solution) at a dose of 10 or 20 mg/kg/day, or placebo for 14 weeks. A subgroup analysis of patients on clobazam and meta-analysis by syndrome were conducted. The primary endpoint was percentage reduction in primary seizure type during the treatment period. RESULTS 396 patients with LGS (49% on clobazam) and 318 patients with DS (64% on clobazam) were included. CBD treatment resulted in a reduction in primary seizure frequency vs placebo in the overall population (treatment ratio [95% confidence interval]: LGS, 0.70 [0.62-0.80]; DS, 0.71 [0.60-0.83]) and in patients receiving clobazam (LGS, 0.56 [0.47-0.67]; DS, 0.63 [0.52-0.77]). The antiseizure efficacy of CBD was also demonstrated across other endpoints vs placebo (≥50% responder rate, total seizure frequency, number of seizure-free days, and Subject/Caregiver Global Impression of Change scores) in the overall populations and in patients receiving clobazam. There were higher incidences of somnolence and sedation in patients on CBD and clobazam. Most incidences of elevated transaminases occurred in patients on concomitant valproate and, to a lesser extent, clobazam. CONCLUSIONS Add-on CBD was effective in reducing seizures in the overall populations and in conjunction with clobazam. Somnolence and sedation occurred more frequently in patients on CBD and clobazam.
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Affiliation(s)
| | | | | | - Hari Bhathal
- Centro Médico TeknonNeurocenter BarcelonaBarcelonaSpain
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Operto FF, Verrotti A, Marrelli A, Ciuffini R, Coppola G, Pastorino GMG, Striano P, Sole M, Zucca C, Manfredi V, Città S, Elia M. Cognitive, adaptive, and behavioral effects of adjunctive rufinamide in Lennox-Gastaut syndrome: A prospective observational clinical study. Epilepsy Behav 2020; 112:107445. [PMID: 32920379 DOI: 10.1016/j.yebeh.2020.107445] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/06/2020] [Accepted: 08/17/2020] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Lennox-Gastaut syndrome (LGS) is a severe pediatric epilepsy syndrome characterized by multiple drug-resistant seizure types. Children with LGS usually experience cognitive regression, and LGS is almost always associated with moderate to severe cognitive impairment. Rufinamide (RFM) was approved by the European Medicines Agency in 2007 for the adjunctive treatment of seizures associated with LGS in patients ≥4 years of age. The primary objective of our study was to assess cognitive, adaptive, and behavior functioning of patients with LGS after 12 months of RFM therapy. METHODS This was an observational, multicenter, prospective study involving 16 patients diagnosed with LGS aged between 7 and 58 years (mean = 22 ± 16.3). Fourteen of 16 patients were already on therapy with 3 antiseizure drugs and 2/16 with 4 antiseizure drugs; RFM has been added with 100 mg/week increments up to a dose of 300-2400 mg/day. The participants and their parents underwent a neuropsychological evaluation for the assessment of intellectual, adaptive, and emotional/behavioral functioning (Leiter International Performance Scale-Revised (LEITER-R), Vineland, and Child Behavior CheckList (CBCL), respectively) before the RFM introduction (baseline) and 12 months after the RFM therapy (T2). Physical and neurological examination, electroencephalography (EEG) recording, seizure type and frequency, and adverse reactions were also considered. RESULTS After 12 months, the total intelligence quotient (IQ) assessed by LEITER-R did not show statistical significant changes, such as there were no statistically significant changes in adaptive functions, assessed by Vineland. Furthermore, there were no statistically significant changes in internalizing and externalizing problems assessed by CBCL. CONCLUSION Adjunctive treatment with RFM did not negatively affect cognitive, adaptive function, and emotional profile in patients with LGS after 1 year of follow-up.
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Affiliation(s)
- Francesca Felicia Operto
- Child and Adolescent Neuropsychiatry Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy.
| | - Alberto Verrotti
- Department of Pediatrics, University of L'Aquila, L'Aquila, Italy
| | - Alfonso Marrelli
- Department of Pediatrics, University of L'Aquila, L'Aquila, Italy
| | - Roberta Ciuffini
- Department of Pediatrics, University of L'Aquila, L'Aquila, Italy
| | - Giangennaro Coppola
- Child and Adolescent Neuropsychiatry Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
| | - Grazia Maria Giovanna Pastorino
- Child and Adolescent Neuropsychiatry Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 'G. Gaslini' Institute, Genova, Italy
| | - Michela Sole
- Pediatric Neurology and Muscular Diseases Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 'G. Gaslini' Institute, Genova, Italy
| | - Claudio Zucca
- Clinical Neurophysiology Unit, Scientific Institute, IRCCS Eugenio Medea, Bosisio Parini, Lecco, Italy
| | - Valentina Manfredi
- Clinical Neurophysiology Unit, Scientific Institute, IRCCS Eugenio Medea, Bosisio Parini, Lecco, Italy
| | - Santina Città
- Oasi Research Institute (IRCCS), Unit of Neurology and Clinical Neurophysiopathology, Troina, Italy
| | - Maurizio Elia
- Oasi Research Institute (IRCCS), Unit of Neurology and Clinical Neurophysiopathology, Troina, Italy
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Abstract
Epilepsy is one of the most common neurologic disorders seen in children, with the highest incidence in the first year of life. Diagnostic accuracy can be challenging because many seizure mimics must be considered. Electroencephalography and neuroimaging can be critical in determining etiology and syndrome. Genetic testing is a high-yield endeavor, particularly in early-life epilepsies. Up to one-fourth of children with epilepsy will develop drug-resistant seizures. Comorbidities are very common in children with epilepsy, including intellectual disability in 25% and learning disability and attention-deficit/hyperactivity disorder in a significant minority. These comorbidities must be recognized and addressed as part of the child's overall care.
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Affiliation(s)
- Anthony Fine
- Division of Epilepsy and Division of Child and Adolescent Neurology, Department of Neurology, Mayo Clinic, Rochester, MN
| | - Elaine C Wirrell
- Division of Epilepsy and Division of Child and Adolescent Neurology, Department of Neurology, Mayo Clinic, Rochester, MN
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Pietrafusa N, Ferretti A, Trivisano M, de Palma L, Calabrese C, Carfì Pavia G, Tondo I, Cappelletti S, Vigevano F, Specchio N. Purified Cannabidiol for Treatment of Refractory Epilepsies in Pediatric Patients with Developmental and Epileptic Encephalopathy. Paediatr Drugs 2019; 21:283-290. [PMID: 31179531 DOI: 10.1007/s40272-019-00341-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND A pharmaceutical grade formulation of cannabidiol (CBD) has been approved for the treatment of Dravet syndrome and Lennox-Gastaut syndrome; however, this formulation is not yet available to patients outside the USA. In addition, CBD is thought to have broad anti-seizure properties that may be beneficial for other types of intractable epilepsy. OBJECTIVE The aim of this study was to evaluate the efficacy, safety and tolerability of artisanal medical CBD oil in patients with developmental and epileptic encephalopathy (DEE) at the tertiary epilepsy center of Bambino Gesù Children's Hospital in Rome, Italy. METHODS This was a single-center, prospective, open-label study. Patients aged from 1 to 18 years with DEE and seizures refractory to appropriate antiepileptic drugs (AEDs) and other alternative treatments (i.e., vagal nerve stimulator and ketogenic diet) were included. Crystalline extract CBD powder (98-99% pure) in an oil artisanal formulation was added to the baseline AED regimen at a dosage of 2-5 mg/kg/day divided for twice-daily administration, then up-titrated until intolerance or a maximum dosage of 25 mg/kg/day was reached. Patients were treated for at least 6 months. Efficacy, safety and tolerability of CBD treatment were assessed through the evaluation of seizure frequency and reports of adverse effects. RESULTS Twenty-nine patients were enrolled in this study (41.4% male). The mean duration of exposure to artisanal CBD was 11.2 months [range 6-25 months; standard deviation (SD) ± 4.4 months]. Mean age at study enrollment was 9.3 years (range 1.9-16.3 years; SD ± 4.7 years). Eleven out of 29 patients (37.9%) had a ≥ 50% improvement in seizure frequency; one patient became seizure free. None of the patients reported worsening seizure frequency; however, 18 patients (62.1%) experienced no beneficial effect regarding seizure frequency. Adverse effects were reported in seven patients (24.14%), most commonly somnolence, decreased appetite and diarrhea. Adverse events were mild and transient, and no dose modification of CBD or other AEDs was required. CONCLUSIONS These data suggest that CBD may have beneficial effects in patients with DEE and an acceptable safety profile. Placebo-controlled randomized trials should be conducted to formally assess the safety and efficacy of CBD in patients with DEE.
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Affiliation(s)
- Nicola Pietrafusa
- Rare and Complex Epilepsy Unit, Division of Neurology, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Alessandro Ferretti
- Rare and Complex Epilepsy Unit, Division of Neurology, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Marina Trivisano
- Rare and Complex Epilepsy Unit, Division of Neurology, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Luca de Palma
- Rare and Complex Epilepsy Unit, Division of Neurology, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Costanza Calabrese
- Rare and Complex Epilepsy Unit, Division of Neurology, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Giusy Carfì Pavia
- Rare and Complex Epilepsy Unit, Division of Neurology, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Ilaria Tondo
- Rare and Complex Epilepsy Unit, Division of Neurology, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Simona Cappelletti
- Rare and Complex Epilepsy Unit, Division of Neurology, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Federico Vigevano
- Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Division of Neurology, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy.
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Arzimanoglou A, Kalilani L, Anamoo MA, Cooney M, Golembesky A, Taeter C, Bozorg A, Tofighy A, Wheless J. Role of observational studies in supporting extrapolation of efficacy data from adults to children with epilepsy - A systematic review of the literature using lacosamide as an example. Eur J Paediatr Neurol 2019; 23:589-603. [PMID: 31171490 DOI: 10.1016/j.ejpn.2019.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 04/08/2019] [Accepted: 05/06/2019] [Indexed: 12/31/2022]
Abstract
Extrapolation of efficacy data from adults to children is accepted for focal epilepsy - the antiepileptic drug, lacosamide, has been approved for the treatment of children ≥4 years of age on this basis. Since many small-scale, open-label studies are reported in the literature before approval, a systematic review was conducted to ascertain whether results of these could be used to support extrapolation in epilepsy in the future. In the absence of randomised trials, a second analysis was conducted for reports on lacosamide use in adults with generalized epilepsies. Twenty-seven articles were included in the paediatric qualitative synthesis, and 14 in the adult. Paediatric studies were analysed separately based on seizure type: focal, generalised and mixed. In focal epilepsy, safety and seizure-related findings mirrored those observed in the adult Phase II/III trials, supporting the feasibility of data extrapolation. Few studies reported outcomes in children with epilepsies associated with generalised seizures, and those that included children with different seizure types, mostly did not provide results separately. Lacosamide treatment appeared beneficial for children and adults experiencing tonic-clonic and myoclonic seizures. Reports of seizure aggravation were inconsistent and, in many cases, could not be clearly attributed to lacosamide. Given the absence of sufficient data, evidence for the feasibility of extrapolation was not as clear-cut as it was in focal epilepsy. These results highlight the complexities of conducting trials in the generalised epilepsy setting, and the importance of studies in the real-life setting and of analysing efficacy data per generalized seizure type and syndrome.
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Affiliation(s)
- A Arzimanoglou
- Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, European Reference Network EpiCARE, University Hospital of Lyon, Lyon, France; Universitat de Barcelona, Department of Child Neurology, Epilepsy Unit, European Reference Network ERN EpiCARE, Hospital San Juan de Deu, Barcelona, Spain.
| | | | | | | | | | | | | | | | - J Wheless
- Chief of Pediatric Neurology, University of Tennessee Health Science Center, Director, Neuroscience Institute and Le Bonheur Comprehensive Epilepsy Program, Le Bonheur Children's Hospital, Memphis, TN, USA
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Patra PH, Barker‐Haliski M, White HS, Whalley BJ, Glyn S, Sandhu H, Jones N, Bazelot M, Williams CM, McNeish AJ. Cannabidiol reduces seizures and associated behavioral comorbidities in a range of animal seizure and epilepsy models. Epilepsia 2019; 60:303-314. [PMID: 30588604 PMCID: PMC6378611 DOI: 10.1111/epi.14629] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 11/26/2018] [Accepted: 11/30/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Epilepsy is a progressive neurological disease characterized by recurrent seizures and behavioral comorbidities. We investigated the antiseizure effect of cannabidiol (CBD) in a battery of acute seizure models. Additionally, we defined the disease-modifying potential of chronic oral administration of CBD on associated comorbidities in the reduced intensity status epilepticus-spontaneous recurrent seizures (RISE-SRS) model of temporal lobe epilepsy (TLE). METHODS We evaluated the acute antiseizure effect of CBD in the maximal electroshock seizure, 6-Hz psychomotor seizure, and pentylenetetrazol acute seizure tests, as well as the corneal kindling model of chronic seizures in mice following intraperitoneal administration. Median effective or behavioral toxic dose was determined in both mice and rats. Next, we tested an intravenous preparation of CBD (10 mg/kg single dose) in a rat model of pilocarpine-induced status epilepticus. We defined the effect of chronic CBD administration (200 mg/kg orally) on spontaneous seizures, motor control, gait, and memory function in the rat RISE-SRS model of TLE. RESULTS CBD was effective in a battery of acute seizure models in both mice and rats following intraperitoneal administration. In the pilocarpine-induced status epilepticus rat model, CBD attenuated maximum seizure severity following intravenous administration, further demonstrating CBD's acute antiseizure efficacy in this rat model. We established that oral CBD attenuated the time-dependent increase in seizure burden and improved TLE-associated motor comorbidities of epileptic rats in the RISE-SRS model without affecting gait. Chronic administration of CBD after the onset of SRS ameliorated reference memory and working memory errors of epileptic animals in a spatial learning and memory task. SIGNIFICANCE The present study illustrates that CBD is a well-tolerated and effective antiseizure agent and illustrates a potential disease-modifying effect of CBD on reducing both seizure burden and associated comorbidities well after the onset of symptomatic seizures in a model of TLE.
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Affiliation(s)
- Pabitra Hriday Patra
- School of PharmacyUniversity of ReadingReadingUnited Kingdom
- School of Psychology and Clinical Language SciencesUniversity of ReadingReadingUnited Kingdom
| | | | - H. Steve White
- Department of PharmacyUniversity of WashingtonSeattleWashington
| | | | - Sarah Glyn
- School of PharmacyUniversity of ReadingReadingUnited Kingdom
- School of Psychology and Clinical Language SciencesUniversity of ReadingReadingUnited Kingdom
| | - Haramrit Sandhu
- School of PharmacyUniversity of ReadingReadingUnited Kingdom
| | | | - Michael Bazelot
- School of PharmacyUniversity of ReadingReadingUnited Kingdom
- GW ResearchCambridgeUnited Kingdom
| | - Claire M. Williams
- School of Psychology and Clinical Language SciencesUniversity of ReadingReadingUnited Kingdom
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11
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Caraballo RH, Flesler S, Reyes Valenzuela G, Fortini S, Chacón S, Ross L, Noli D. Sulthiame add-on therapy in children with Lennox-Gastaut syndrome: A study of 44 patients. Seizure 2018; 62:55-58. [DOI: 10.1016/j.seizure.2018.09.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 09/21/2018] [Accepted: 09/24/2018] [Indexed: 10/28/2022] Open
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12
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Lattanzi S, Brigo F, Cagnetti C, Trinka E, Silvestrini M. Efficacy and Safety of Adjunctive Cannabidiol in Patients with Lennox-Gastaut Syndrome: A Systematic Review and Meta-Analysis. CNS Drugs 2018; 32:905-916. [PMID: 30132269 DOI: 10.1007/s40263-018-0558-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Lennox-Gastaut syndrome (LGS) is a severe developmental epileptic encephalopathy, and available interventions fail to control seizures in most patients. Cannabidiol (CBD) is a major chemical of marijuana, which has anti-seizure properties and different mechanisms of action compared with other approved antiepileptic drugs (AEDs). OBJECTIVE The aim was to evaluate the efficacy and safety of CBD as adjunctive treatment for seizures in patients with LGS using meta-analytical techniques. METHODS Randomized, placebo-controlled, single- or double-blinded trials were identified. Main outcomes included the ≥ 50% reduction in baseline drop and non-drop seizure frequency, and the incidence of treatment withdrawal and adverse events (AEs). Risk ratios (RRs) with 95% confidence intervals (CIs) were estimated through the inverse variance method. RESULTS Two trials were included involving 396 participants. Patients presenting ≥ 50% reduction in drop seizure frequency during the treatment were 40.0% with CBD and 19.3% with placebo [RR 2.12 (95% CI 1.48-3.03); p < 0.001]. The rate of non-drop seizure frequency was reduced by 50% or more in 49.4% of patients in the CBD and 30.4% in the placebo arms [RR 1.62 (95% CI 1.09-2.43); p = 0.018]. The RR for CBD withdrawal was 4.93 (95% CI 1.50-16.22; p = 0.009). The RR to develop any AE during CBD treatment was 1.24 (95% CI 1.11-1.38; p < 0.001). AEs significantly associated with CBD were somnolence, decreased appetite, diarrhea and increased serum aminotransferases. CONCLUSIONS Adjunctive CBD resulted in a greater reduction in seizure frequency and a higher rate of AEs than placebo in patients with LGS presenting seizures uncontrolled by concomitant AEDs.
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Affiliation(s)
- Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Via Conca 71, 60020, Ancona, Italy.
| | - Francesco Brigo
- Department of Neuroscience, Biomedicine and Movement Science, University of Verona, Verona, Italy.,Division of Neurology, "Franz Tappeiner" Hospital, Merano, BZ, Italy
| | - Claudia Cagnetti
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Via Conca 71, 60020, Ancona, Italy
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria.,Center for Cognitive Neuroscience, Salzburg, Austria.,Public Health, Health Services Research and HTA, University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Via Conca 71, 60020, Ancona, Italy
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13
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Kang JW, Eom S, Hong W, Kwon HE, Park S, Ko A, Kang HC, Lee JS, Lee YM, Kim DS, Kim HD. Long-term Outcome of Resective Epilepsy Surgery in Patients With Lennox-Gastaut Syndrome. Pediatrics 2018; 142:peds.2018-0449. [PMID: 30194277 DOI: 10.1542/peds.2018-0449] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2018] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE We aimed to evaluate the long-term outcome of resective epilepsy surgery in patients with Lennox-Gastaut syndrome (LGS). METHODS We reviewed the case reports of 90 patients with LGS who had undergone resective surgery between 2003 and 2014 at the Severance Children's Hospital and managed them for a minimum period of 2 years. RESULTS At the time of surgery, the patients were between 3.0 and 23.5 years old (mean ± SD: 9.3 ± 4.4). The time from seizure onset to surgery ranged from 0.7 to 20.1 years (7.2 ± 4.3). On postoperative follow-up for an average period of 6.1 ± 2.2 years (range: 2.1-11.4 years), 45 patients (50.0%) had no seizures, and 15 (16.7%) reported infrequent seizures. Seizure-free outcomes were achieved in 15 of the 21 (71.4%) hemispherectomies, 23 of the 51 (45.1%) multilobar resections, and 7 of the 18 (38.9%) single lobar resections. On high-resolution MRIs, 20 patients (22.2%) had negative findings, 8 of whom (40.0%) became seizure-free after resective surgery. Malformation of cortical development was the most common pathologic finding and was noted in 57 patients (63.3%). Seizure-free patients achieved better adaptive behavior and social competence than did patients with persistent seizures at the second (2-3 years after surgery) and third (4-6 years after surgery) follow-ups, as indicated by social quotients (P < .05). CONCLUSIONS Resective surgery is a viable option in some patients to treat seizures that are associated with LGS, with a high probability of seizure control and better adaptive function.
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Affiliation(s)
- Joon Won Kang
- Departments of Pediatrics and Medical Science, Chungnam National University Hospital and College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Soyong Eom
- Epilepsy Research Institute, College of Medicine
| | - William Hong
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Hye Eun Kwon
- Department of Pediatrics, International St Mary's Hospital and College of Medicine, Catholic Kwandong University, Incheon, Republic of Korea; and
| | - Soyoung Park
- Department of Pediatrics, Soon Chun Hyang University Hospital and College of Medicine, Soonchunhyang University, Bucheon, Republic of Korea
| | - Ara Ko
- Epilepsy Research Institute, College of Medicine.,Pediatric Epilepsy Clinics, Division of Pediatric Neurology, Department of Pediatrics, Severance Children's Hospital
| | - Hoon-Chul Kang
- Epilepsy Research Institute, College of Medicine.,Pediatric Epilepsy Clinics, Division of Pediatric Neurology, Department of Pediatrics, Severance Children's Hospital
| | - Joon Soo Lee
- Epilepsy Research Institute, College of Medicine.,Pediatric Epilepsy Clinics, Division of Pediatric Neurology, Department of Pediatrics, Severance Children's Hospital
| | - Young-Mock Lee
- Department of Pediatrics, Gangnam Severance Hospital, and
| | - Dong Seok Kim
- Division of Pediatric Neurosurgery, Severance Hospital, Yonsei University, Seoul, Republic of Korea
| | - Heung Dong Kim
- Epilepsy Research Institute, College of Medicine, .,Pediatric Epilepsy Clinics, Division of Pediatric Neurology, Department of Pediatrics, Severance Children's Hospital
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14
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Ostrovsky DA, Ehrlich A. Addition of Cannabidiol to Current Antiepileptic Therapy Reduces Drop Seizures in Children and Adults With Treatment-Resistant Lennox-Gastaut Syndrome. Explore (NY) 2018; 14:311-313. [PMID: 29887290 DOI: 10.1016/j.explore.2018.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Thiele EA, Marsh ED, French JA, Mazurkiewicz-Beldzinska M, Benbadis SR, Joshi C, Lyons PD, Taylor A, Roberts C, Sommerville K. Cannabidiol in patients with seizures associated with Lennox-Gastaut syndrome (GWPCARE4): a randomised, double-blind, placebo-controlled phase 3 trial. Lancet 2018; 391:1085-1096. [PMID: 29395273 DOI: 10.1016/s0140-6736(18)30136-3] [Citation(s) in RCA: 514] [Impact Index Per Article: 85.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 10/20/2017] [Accepted: 10/24/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients with Lennox-Gastaut syndrome, a rare, severe form of epileptic encephalopathy, are frequently treatment resistant to available medications. No controlled studies have investigated the use of cannabidiol for patients with seizures associated with Lennox-Gastaut syndrome. We therefore assessed the efficacy and safety of cannabidiol as an add-on anticonvulsant therapy in this population of patients. METHODS In this randomised, double-blind, placebo-controlled trial done at 24 clinical sites in the USA, the Netherlands, and Poland, we investigated the efficacy of cannabidiol as add-on therapy for drop seizures in patients with treatment-resistant Lennox-Gastaut syndrome. Eligible patients (aged 2-55 years) had Lennox-Gastaut syndrome, including a history of slow (<3 Hz) spike-and-wave patterns on electroencephalogram, evidence of more than one type of generalised seizure for at least 6 months, at least two drop seizures per week during the 4-week baseline period, and had not responded to treatment with at least two antiepileptic drugs. Patients were randomly assigned (1:1) using an interactive voice response system, stratified by age group, to receive 20 mg/kg oral cannabidiol daily or matched placebo for 14 weeks. All patients, caregivers, investigators, and individuals assessing data were masked to group assignment. The primary endpoint was percentage change from baseline in monthly frequency of drop seizures during the treatment period, analysed in all patients who received at least one dose of study drug and had post-baseline efficacy data. All randomly assigned patients were included in the safety analyses. This study is registered with ClinicalTrials.gov, number NCT02224690. FINDINGS Between April 28, 2015, and Oct 15, 2015, we randomly assigned 171 patients to receive cannabidiol (n=86) or placebo (n=85). 14 patients in the cannabidiol group and one in the placebo group discontinued study treatment; all randomly assigned patients received at least one dose of study treatment and had post-baseline efficacy data. The median percentage reduction in monthly drop seizure frequency from baseline was 43·9% (IQR -69·6 to -1·9) in the cannibidiol group and 21·8% (IQR -45·7 to 1·7) in the placebo group. The estimated median difference between the treatment groups was -17·21 (95% CI -30·32 to -4·09; p=0·0135) during the 14-week treatment period. Adverse events occurred in 74 (86%) of 86 patients in the cannabidiol group and 59 (69%) of 85 patients in the placebo group; most were mild or moderate. The most common adverse events were diarrhoea, somnolence, pyrexia, decreased appetite, and vomiting. 12 (14%) patients in the cannabidiol group and one (1%) patient in the placebo group withdrew from the study because of adverse events. One patient (1%) died in the cannabidiol group, but this was considered unrelated to treatment. INTERPRETATION Add-on cannabidiol is efficacious for the treatment of patients with drop seizures associated with Lennox-Gastaut syndrome and is generally well tolerated. The long-term efficacy and safety of cannabidiol is currently being assessed in the open-label extension of this trial. FUNDING GW Pharmaceuticals.
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Affiliation(s)
- Elizabeth A Thiele
- Pediatric Epilepsy Program, Massachusetts General Hospital, Boston, MA, USA.
| | - Eric D Marsh
- Division of Child Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jacqueline A French
- Department of Neurology, New York University School of Medicine, New York, NY, USA
| | | | | | | | - Paul D Lyons
- Winchester Neurological Consultants, Winchester, VA, USA
| | | | | | - Kenneth Sommerville
- Greenwich Biosciences, Research Triangle Park, NC, USA; Duke University, Durham, NC, USA
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16
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Porcari GS, Fu C, Doll ED, Carter EG, Carson RP. Efficacy of artisanal preparations of cannabidiol for the treatment of epilepsy: Practical experiences in a tertiary medical center. Epilepsy Behav 2018; 80:240-246. [PMID: 29429908 DOI: 10.1016/j.yebeh.2018.01.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 01/22/2018] [Accepted: 01/23/2018] [Indexed: 01/08/2023]
Abstract
Medically refractory epilepsy continues to be a challenge worldwide, and despite an increasing number of medical therapies, approximately 1 in 3 patients continues to have seizures. Cannabidiol (CBD), one of many constituents of the Cannabis sativa or marijuana plant, has received renewed interest in the treatment of epilepsy. While highly purified CBD awaits Food and Drug Administration (FDA) approval, artisanal formulations of CBD are readily available and are seeing increased use in our patient population. Although randomized controlled trials of CBD are ongoing and promising, data regarding artisanal formulations of CBD are minimal and largely anecdotal. Here, we report a retrospective study to define the efficacy of artisanal CBD preparations in children with epilepsy. Given the known interaction between CBD and clobazam, we also conducted a subgroup comparison to determine if clobazam use was related to any beneficial effects of CBD. Additionally, we compared response rates with CBD and with clobazam alone within an overlapping patient cohort. A pediatric cohort with epilepsy of 108 patients was identified through a medical record search for patients using CBD oil. The addition of CBD resulted in 39% of patients having a >50% reduction in seizures, with 10% becoming seizure-free. The responder rate for clobazam was similar. No patients achieved CBD monotherapy, although the weaning of other antiepileptic drugs (AEDs) became possible in 22% of patients. A comparable proportion had AED additions during CBD therapy. With concomitant use of clobazam, 44% of patients had a 50% reduction in seizures upon addition of CBD compared with 33% in the population not taking clobazam; this difference was not statistically significant. The most common reported side effect of CBD was sedation in less than 4% of patients, all of whom were also taking clobazam. Increased alertness and improved verbal interactions were reported in 14% of patients in the CBD group and 8% of patients in the CBD and clobazam group. Benefits were more marked in the CBD alone group, in contrast to the CBD and clobazam group, but this difference was not statistically significant. In summary, these findings support efficacy of artisanal CBD preparations in seizure reduction with few significant side effects. The response to CBD was independent of concurrent clobazam use, although clobazam may contribute to the sedation seen with concurrent CBD use.
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Affiliation(s)
| | - Cary Fu
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University, Nashville, TN, USA
| | - Emily D Doll
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University, Nashville, TN, USA
| | - Emma G Carter
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University, Nashville, TN, USA
| | - Robert P Carson
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University, Nashville, TN, USA.
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17
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Abstract
PURPOSE OF REVIEW The overlap of neuropsychiatric illness and developmental disability continues to be prominently recognized in clinical practice and in the academic literature. Theoretical and practical considerations may represent a frontier for understanding brain and behavior relationships. The purpose of this review is to explore this common relationship and report on recent literature that helps advance the larger fields of psychiatry and neurology. RECENT FINDINGS Overlap between developmental disability, epilepsy, and neuropsychiatric illness may be more common than originally thought. Excessive excitatory neurotransmitter activity may be present in epilepsy and in autism spectrum disorder. Specific seizure types may be associated with features of developmental disabilities and neuropsychiatric conditions. SUMMARY Neuropsychiatric illness is common in epilepsy and more frequent in developmental disabilities than generally recognized. Seizure foci in the temporal lobe may play a significant role. Brain connectivity and specific neurotransmitter systems are active areas of investigation. Antiepileptic drugs may improve neuropsychiatric symptoms in persons with developmental disability and epilepsy.
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18
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Abstract
Childhood epileptic encephalopathies are age-dependent disorders of the brain whose hallmarks include loss of neurologic function over time, abnormal electroencephalographic findings, and seizures. Ictal and interictal electrographic activity are conjointly thought to be at the root of the often devastating neuropsychological deterioration, which is specific to the maturing brain. The goals of treatment are not only to control seizures, but also to prevent or reverse neurologic loss of function. In general, time is of the essence in diagnosis, and experienced specialists should promptly design a treatment plan. Hormonal and immune therapies are at the forefront of treatment in many cases, with traditional antiepileptic drugs and surgery (when an identifiable lesion is present) playing a limited role. However, gold standard evidence for treatment of epileptic encephalopathies remains limited. Ongoing clinical and basic research may lead to better understanding of these catastrophic conditions and to better and more effective therapies.
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Affiliation(s)
- Hiroki Nariai
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Susan Duberstein
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA,Department of Pediatrics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY, USA
| | - Shlomo Shinnar
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA,Department of Pediatrics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY, USA,Department of Epidemiology and Population Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY, USA
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19
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Piña-Garza JE, Montouris GD, Vekeman F, Cheng WY, Tuttle E, Giguere-Duval P, Duh MS, Shen V, Saurer TB, Isojarvi J. Assessment of treatment patterns and healthcare costs associated with probable Lennox-Gastaut syndrome. Epilepsy Behav 2017; 73:46-50. [PMID: 28609734 DOI: 10.1016/j.yebeh.2017.05.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 05/15/2017] [Indexed: 10/19/2022]
Abstract
Lennox-Gastaut syndrome (LGS) is a chronic and severe form of epilepsy characterized by intractable seizures, cognitive impairment, and abnormal electroencephalogram findings with slow spike-wave complexes. It typically presents before age 8, but symptoms continue into adulthood and require lifelong treatment associated with significant clinical burden. Data on LGS-associated healthcare utilization and costs are limited. In this study we use a claims-based LGS classifier based on random forest methodology to identify patients with probable LGS from the a Medicaid multi-state database and assess its prevalence across the age spectrum, healthcare utilization, treatment patterns, costs, and comorbid conditions. The classifier identified patients with probable LGS across all ages, with up to 8% of 10-year-old patients with epilepsy identified as having probable LGS. The prevalence of probable LGS was lower in older age cohorts, indicating that it may be under-recognized in older patients. Our analysis showed that probable LGS is associated with considerably higher total healthcare and medical costs than non-LGS patients. The costs were generally consistent between age cohorts, suggesting that the cost burden extends beyond childhood and has a lifelong impact. Analysis of treatment patterns suggest that while the majority of probable LGS patients in this study received widest-spectrum AEDs, a considerable proportion did not and therefore may have been inadequately treated. Further, usage of clobazam and rufinamide was decreased in older compared to younger patient cohorts, indicating that older patient cohorts are less likely to be receiving optimum treatment for LGS. These findings indicate the need for increased clinical attention to LGS beyond pediatric years, with a focus on optimization of treatment for LGS patients of all ages with widest-spectrum AEDs. Timely recognition and adequate treatment of LGS are likely to result in improved outcomes and less costly management of this condition.
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Affiliation(s)
- J Eric Piña-Garza
- The Children's Hospital at TriStar Centennial Medical Center, Nashville, TN, USA.
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20
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François C, Stern JM, Ogbonnaya A, Lokhandwala T, Landsman-Blumberg P, Duhig A, Shen V, Tan R. Use and cost comparison of clobazam to other antiepileptic drugs for treatment of Lennox-Gastaut syndrome. JOURNAL OF MARKET ACCESS & HEALTH POLICY 2017; 5:1318691. [PMID: 28740620 PMCID: PMC5508372 DOI: 10.1080/20016689.2017.1318691] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 03/31/2017] [Indexed: 06/07/2023]
Abstract
Background: Lennox-Gastaut syndrome (LGS) is a severe form of childhood-onset epilepsy associated with serious injuries due to frequent and severe seizures. Of the antiepileptic drugs (AEDs) approved for LGS, clobazam is a more recent market entrant, having been approved in October 2011. Recent AED budget impact and cost-effectiveness analyses for LGS suggest that adding clobazam to a health plan formulary may result in decreased medical costs; however, research on clinical and economic outcomes and treatment patterns with these AED treatments in LGS is limited. Objectives: To compare the baseline characteristics and treatment patterns of new initiators of clobazam and other AEDs among LGS patients and compare healthcare utilization and costs before and after clobazam initiation among LGS patients. Methods: A retrospective study of probable LGS patients was conducted using the MarketScan® Commercial, Medicare Supplemental, and Medicaid databases (10/1/2010-3/31/2014). Results: In the Commercial/Medicare Supplemental population, clobazam users were younger, had fewer comorbidities, and more prior AED use than non-clobazam users. In the 12 months pre-treatment initiation, clobazam users had significantly more seizure-related inpatient stays and outpatient visits and higher total seizure-related (P < 0.001) and all-cause (P < 0.001) costs than non-clobazam users. Among clobazam users, when compared to the 12 months pre-clobazam initiation, seizure-related medical utilization and costs were lower in the 12 months post-clobazam initiation (P = 0.004). Total all-cause (P < 0.001) and seizure-related (P = 0.029) costs increased post-clobazam initiation mainly due to the increase in outpatient pharmacy costs. Similar results were observed in the Medicaid population. Conclusions: Baseline results suggest a prescribing preference for clobazam in severe LGS patients. Clobazam users had a reduction in seizure-related medical utilization and costs after clobazam initiation. The improvement in medical costs mostly offset the higher prescription costs following clobazam initiation.
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Affiliation(s)
- Clément François
- Health Economics and Outcomes Research, Lundbeck, LLC, Deerfield, IL, USA
| | - John M Stern
- Department of Neurology, University of California, Los Angeles, Los Angeles, CA, USA
| | | | | | | | - Amy Duhig
- Scientific Consulting, Xcenda, LLC, Palm Harbor, FL, USA
| | - Vivienne Shen
- Health Economics and Outcomes Research, Lundbeck, LLC, Deerfield, IL, USA
| | - Robin Tan
- Scientific Consulting, Xcenda, LLC, Palm Harbor, FL, USA
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21
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Kothare S, Kluger G, Sachdeo R, Williams B, Olhaye O, Perdomo C, Bibbiani F. Dosing considerations for rufinamide in patients with Lennox–Gastaut syndrome: Phase III trial results and real-world clinical data. Seizure 2017; 47:25-33. [DOI: 10.1016/j.seizure.2017.02.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 01/13/2017] [Accepted: 02/16/2017] [Indexed: 11/25/2022] Open
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Affiliation(s)
- Carl E. Stafstrom
- Division of Pediatric Neurology, John M. Freeman Pediatric Epilepsy Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Eric H. Kossoff
- Division of Pediatric Neurology, John M. Freeman Pediatric Epilepsy Center, Johns Hopkins University School of Medicine, Baltimore, MD
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23
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Herbst SM, Proepper CR, Geis T, Borggraefe I, Hahn A, Debus O, Haeussler M, von Gersdorff G, Kurlemann G, Ensslen M, Beaud N, Budde J, Gilbert M, Heiming R, Morgner R, Philippi H, Ross S, Strobl-Wildemann G, Muelleder K, Vosschulte P, Morris-Rosendahl DJ, Schuierer G, Hehr U. LIS1-associated classic lissencephaly: A retrospective, multicenter survey of the epileptogenic phenotype and response to antiepileptic drugs. Brain Dev 2016; 38:399-406. [PMID: 26494205 DOI: 10.1016/j.braindev.2015.10.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 09/30/2015] [Accepted: 10/01/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Patients with LIS1-associated classic lissencephaly typically present with severe psychomotor retardation and drug-resistant epilepsy within the first year. AIM To analyze the epileptogenic phenotype and response to antiepileptic therapy in LIS1-associated classic lissencephaly. METHOD Retrospective evaluation of 22 patients (8 months-24 years) with genetically and radiologically confirmed LIS1-associated classic lissencephaly in 16 study centers. RESULTS All patients in our cohort developed drug-resistant epilepsy. In 82% onset of seizures was noted within the first six months of life, most frequently with infantile spasms. Later in infancy the epileptogentic phenotype became more variable and included different forms of focal seizures as well generalized as tonic-clonic seizures, with generalized tonic-clonic seizures being the predominant type. Lamotrigine and valproate were rated most successful with good or partial response rates in 88-100% of the patients. Both were evaluated significantly better than levetiracetam (p<0.05) and sulthiame (p<0.01) in the neuropediatric assessment and better than levetiracetam, sulthiame (p<0.05) and topiramate (p<0.01) in the family survey. Phenobarbital and vigabatrin achieved good or partial response in 62-83% of the patients. CONCLUSION Our findings suggest that patients with LIS1-associated lissencephaly might benefit most from lamotrigine, valproate, vigabatrin or phenobarbital.
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Affiliation(s)
- Saskia M Herbst
- Center for and Institute of Human Genetics, University of Regensburg, Regensburg, Germany.
| | - Christiane R Proepper
- Center for and Institute of Human Genetics, University of Regensburg, Regensburg, Germany
| | - Tobias Geis
- Department of Pediatric Neurology, Klinik St. Hedwig, University Children's Hospital Regensburg (KUNO), Regensburg, Germany
| | - Ingo Borggraefe
- Department of Pediatric Neurology, Developmental Medicine and Social Pediatrics, Children's Hospital, University of Munich, Munich, Germany
| | | | - Otfried Debus
- Clemenshospital, Children's Hospital, Münster, Germany
| | - Martin Haeussler
- Frühdiagnosezentrum Würzburg, University Children's Hospital, Würzburg, Germany
| | | | - Gerhard Kurlemann
- University Children's Hospital Muenster, Department of General Pediatrics, Neuropediatrics, Münster, Germany
| | - Matthias Ensslen
- Department of Pediatric Neurology, Developmental Medicine and Social Pediatrics, Children's Hospital, University of Munich, Munich, Germany
| | - Nathalie Beaud
- Department of Neuropediatrics, Westküstenklinikum Heide, Heide, Germany
| | - Joerg Budde
- Department of Pediatrics St. Hedwig, St. Josefskrankenhaus Freiburg, Freiburg, Germany
| | | | | | | | - Heike Philippi
- Center of Developmental Neurology Frankfurt, Frankfurt, Germany
| | - Sophia Ross
- Pediatric Neurology, University Children's Hospital Erlangen, Erlangen, Germany
| | | | | | | | - Deborah J Morris-Rosendahl
- Genomic Medicine, National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, London, United Kingdom
| | - Gerhard Schuierer
- Center for Neuroradiology, Bezirksklinikum Regensburg, University Medical Center, Regensburg, Germany
| | - Ute Hehr
- Center for and Institute of Human Genetics, University of Regensburg, Regensburg, Germany
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Liao H, Jiang G, Wang X. Music therapy as a non-pharmacological treatment for epilepsy. Expert Rev Neurother 2015. [DOI: 10.1586/14737175.2015.1071191] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Millichap JG, Millichap JJ. Differential Diagnosis of Lennox-Gastaut Syndrome. Pediatr Neurol Briefs 2014. [DOI: 10.15844/pedneurbriefs-28-12-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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