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Ben Said M, Jallouli O, Ben Aissa A, Souissi A, Kamoun F, Fakhfakh F, Masmoudi S, Ben Ayed I, Charfi Triki C. Customized targeted massively parallel sequencing enables the identification of novel pathogenic variants in Tunisian patients with developmental and epileptic encephalopathy. Epilepsia Open 2024; 9:1697-1709. [PMID: 37867425 PMCID: PMC11450609 DOI: 10.1002/epi4.12848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/16/2023] [Indexed: 10/24/2023] Open
Abstract
OBJECTIVE To develop a high-throughput sequencing panel for the diagnosis of developmental and epileptic encephalopathy in Tunisia and to clarify the frequency of disease-causing genes in this region. METHODS We developed a custom panel for next-generation sequencing of the coding sequences of 116 genes in individuals with developmental and epileptic encephalopathy from the Tunisian population. Segregation analyses and in silico studies have been conducted to assess the identified variants' pathogenicity. RESULTS We report 12 pathogenic variants in SCN1A, CHD2, CDKL5, SZT2, KCNT1, GNAO1, PCDH19, MECP2, GRIN2A, and SYNGAP1 in patients with developmental and epileptic encephalopathy. Five of these variants are novel: "c.149delA, p.(Asn50MetfsTer26)" in CDKL5; "c.3616C > T, p.(Arg1206Ter)" in SZT2; "c.111_113del, p.(Leu39del)" in GNAO1; "c.1435G>C, p.(Asp479His)" in PCDH19; and "c.2143delC, p.(Arg716GlyfsTer10)" in SYNGAP1. Additionally, for four of our patients, the genetic result facilitated the choice of the appropriate treatment. SIGNIFICANCE This is the first report of a custom gene panel to identify genetic variants implicated in developmental and epileptic encephalopathy in the Tunisian population as well as the North African region (Tunisia, Egypt, Libya, Algeria, Morocco) with a diagnostic rate of 30%. This high-throughput sequencing panel has considerably improved the rate of positive diagnosis of developmental and epileptic encephalopathy in the Tunisian population, which was less than 15% using Sanger sequencing. The benefit of genetic testing in these patients was approved by both physicians and parents.
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Affiliation(s)
- Mariem Ben Said
- Laboratory of Molecular and Cellular Screening Processes, Center of Biotechnology of SfaxUniversity of SfaxSfaxTunisia
| | - Olfa Jallouli
- Department of Child Neurology, Hedi Chaker Hospital, LR19ES15University of SfaxSfaxTunisia
| | - Abir Ben Aissa
- Department of Child Neurology, Hedi Chaker Hospital, LR19ES15University of SfaxSfaxTunisia
| | - Amal Souissi
- Laboratory of Molecular and Cellular Screening Processes, Center of Biotechnology of SfaxUniversity of SfaxSfaxTunisia
| | - Fatma Kamoun
- Department of Child Neurology, Hedi Chaker Hospital, LR19ES15University of SfaxSfaxTunisia
| | - Faiza Fakhfakh
- Molecular Genetics and Functional Laboratory, Faculty of Science of SfaxUniversity of SfaxSfaxTunisia
| | - Saber Masmoudi
- Laboratory of Molecular and Cellular Screening Processes, Center of Biotechnology of SfaxUniversity of SfaxSfaxTunisia
| | - Ikhlas Ben Ayed
- Laboratory of Molecular and Cellular Screening Processes, Center of Biotechnology of SfaxUniversity of SfaxSfaxTunisia
| | - Chahnez Charfi Triki
- Department of Child Neurology, Hedi Chaker Hospital, LR19ES15University of SfaxSfaxTunisia
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Wirrell EC, Lagae L, Scheffer IE, Cross JH, Specchio N, Strzelczyk A. Practical considerations for the use of fenfluramine to manage patients with Dravet syndrome or Lennox-Gastaut syndrome in clinical practice. Epilepsia Open 2024; 9:1643-1657. [PMID: 38962968 PMCID: PMC11450599 DOI: 10.1002/epi4.12998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 05/20/2024] [Accepted: 06/04/2024] [Indexed: 07/05/2024] Open
Abstract
Fenfluramine (FFA), an antiseizure medication (ASM) with serotonergic and sigma-1 receptor activity, is used to manage patients with developmental and epileptic encephalopathies (DEEs). It is approved in the US for treating seizures associated with Dravet syndrome (DS) and Lennox-Gastaut syndrome (LGS) in patients ≥2 years old and as add-on therapy for seizures associated with DS and LGS in the EU, UK, and Japan in similarly aged patients. Consensus guidelines for treatment of DS have recommended FFA to be an early-line ASM, and it has also shown efficacy in managing seizures associated with LGS. DS and LGS are DEEs associated with a range of seizure types, developmental impairments, and multiple comorbidities. Here we provide case vignettes describing 4 patients (3 DS and 1 LGS) aged 4-29 years old in whom up to 14 ASMs had previously failed, to illustrate real-world practice issues encountered by neurologists. This review provides guidance on the use of FFA in the context of ASM polytherapy and drug-drug interactions (DDIs), behavioral issues, dose titration, and adverse events. Along with data from the clinical trial program, these case vignettes emphasize the low risk of DDIs, a generally well-tolerated safety profile, and other seizure and nonseizure benefits (eg, improved cognition and sleep) associated with the use of FFA in DS or LGS. PLAIN LANGUAGE SUMMARY: Fenfluramine is used to treat seizures in individuals with Dravet syndrome and Lennox-Gastaut syndrome, but there are a range of issues that clinicians may face when treating patients. This review highlights four patients from the authors' everyday clinical work and offers guidance and practical considerations by neurologists with expertise in managing these complex conditions related to drug interactions, dosing, and side effects associated with fenfluramine.
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Affiliation(s)
- Elaine C. Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Department of NeurologyMayo ClinicRochesterMinnesotaUSA
| | - Lieven Lagae
- Member of the European Reference Network EpiCARE, Department of Pediatric NeurologyUniversity of LeuvenLeuvenBelgium
| | - Ingrid E. Scheffer
- Austin Hospital and Royal Children’'s Hospital, Florey and Murdoch Children's Research InstitutesUniversity of MelbourneMelbourneVictoriaAustralia
| | - J. Helen Cross
- Developmental Neurosciences Research & Teaching DepartmentUCL NIHR BRC Great Ormond Street Institute of Child HealthLondonUK
- Department of NeurologyGreat Ormond Street HospitalLondonUK
| | - Nicola Specchio
- Neurology, Epilepsy and Movement Disorders UnitBambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network EpiCARERomeItaly
| | - Adam Strzelczyk
- Goethe‐University Frankfurt, Epilepsy Center Frankfurt Rhine‐Main and Department of NeurologyUniversity Hospital FrankfurtFrankfurt am MainGermany
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Gjerulfsen CE, Nikanorova M, Olofsson K, Johannessen Landmark C, Rubboli G, Møller RS. Fenfluramine treatment in pediatric patients with Dravet syndrome reduces seizure burden and overall healthcare costs: A retrospective and observational real-world study. Epilepsia Open 2024; 9:1891-1900. [PMID: 39140199 PMCID: PMC11450588 DOI: 10.1002/epi4.13029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 07/14/2024] [Accepted: 07/28/2024] [Indexed: 08/15/2024] Open
Abstract
OBJECTIVES Dravet syndrome is a developmental and epileptic encephalopathy characterized by early onset epilepsy with multiple seizure types often intractable to treatment. Randomized clinical trials have demonstrated how treatment with fenfluramine significantly reduces seizure frequency in patients with Dravet syndrome. The study aims to (1) describe the efficacy and tolerability of fenfluramine in a Danish cohort of patients with Dravet syndrome; and (2) evaluate whether treatment with fenfluramine reduces epilepsy-related hospital contacts administrated by pediatricians or epilepsy-trained nurses. METHODS A retrospective registry-based cohort study at the Danish Epilepsy Centre, Filadelfia, Dianalund, Denmark, enrolled 30 pediatric patients with Dravet syndrome treated with fenfluramine between 2017 and 2023. RESULTS Thirty patients with Dravet syndrome (aged 3-21 years, 12 females) with a verified pathogenic SCN1A variant were included. They were treated with fenfluramine at a mean duration of 29 months with a mean maintenance dose of 0.5 mg/kg/day. The number of patient-years on treatment was 75 years. At last follow-up, 6 patients had discontinued treatment due to lack of efficacy or adverse effects. In the remaining 24 patients, generalized tonic-clonic seizures were reduced by ≥30% in 83%, by ≥50% in 67%, and by 100% in 25%. Additionally, 71% of the patients were reduced in concomitant anti-seizure medication, and 75% experienced a reduction (mean reduction at 52%, range 11%-94%) in epilepsy-related hospital contacts from baseline to the end of the treatment period. SIGNIFICANCE Treatment with fenfluramine effectively reduced seizure frequency and concomitant antiseizure medication in patients with Dravet syndrome. Furthermore, a decrease in epilepsy-related contacts by 80% was observed over 6 years of treatment, which may indicate cost-effective benefits. PLAIN LANGUAGE SUMMARY Patients with Dravet syndrome suffer from severe epileptic seizures that are difficult to treat with medication. Earlier, treatment with fenfluramine (an anti-seizure medication) has been documented to decrease the total number of seizures in patients with Dravet syndrome. This publication summarizes the experiences with fenfluramine in children with Dravet syndrome at the Danish Epilepsy Centre, Filadelfia, Dianalund, Denmark. Our publication also illustrates that treatment with fenfluramine may reduce the patients' number of yearly contacts with doctors and nurses specialized in epilepsy treatment, which may indicate cost-effectiveness.
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Affiliation(s)
- Cathrine E. Gjerulfsen
- Department of Epilepsy Genetics and Personalized MedicineDanish Epilepsy Centre, Filadelfia (Member of ERN EpiCARE)DianalundDenmark
- Department of Regional Health Research, Faculty of Health SciencesUniversity of Southern DenmarkOdenseDenmark
| | | | - Kern Olofsson
- Department of Child NeurologyDanish Epilepsy CentreDianalundDenmark
| | - Cecilie Johannessen Landmark
- Department of PharmacyOslo Metropolitan University (Member of the ERN EpiCare)OsloNorway
- The National Center for EpilepsyOslo University HospitalOsloNorway
- Department of PharmacologyOslo University HospitalOsloNorway
| | - Guido Rubboli
- Department of Epilepsy Genetics and Personalized MedicineDanish Epilepsy Centre, Filadelfia (Member of ERN EpiCARE)DianalundDenmark
- Institute of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
| | - Rikke S. Møller
- Department of Epilepsy Genetics and Personalized MedicineDanish Epilepsy Centre, Filadelfia (Member of ERN EpiCARE)DianalundDenmark
- Department of Regional Health Research, Faculty of Health SciencesUniversity of Southern DenmarkOdenseDenmark
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Scheffer IE, Zuberi S, Mefford HC, Guerrini R, McTague A. Developmental and epileptic encephalopathies. Nat Rev Dis Primers 2024; 10:61. [PMID: 39237642 DOI: 10.1038/s41572-024-00546-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/29/2024] [Indexed: 09/07/2024]
Abstract
Developmental and epileptic encephalopathies, the most severe group of epilepsies, are characterized by seizures and frequent epileptiform activity associated with developmental slowing or regression. Onset typically occurs in infancy or childhood and includes many well-defined epilepsy syndromes. Patients have wide-ranging comorbidities including intellectual disability, psychiatric features, such as autism spectrum disorder and behavioural problems, movement and musculoskeletal disorders, gastrointestinal and sleep problems, together with an increased mortality rate. Problems change with age and patients require substantial support throughout life, placing a high psychosocial burden on parents, carers and the community. In many patients, the aetiology can be identified, and a genetic cause is found in >50% of patients using next-generation sequencing technologies. More than 900 genes have been identified as monogenic causes of developmental and epileptic encephalopathies and many cell components and processes have been implicated in their pathophysiology, including ion channels and transporters, synaptic proteins, cell signalling and metabolism and epigenetic regulation. Polygenic risk score analyses have shown that common variants also contribute to phenotypic variability. Holistic management, which encompasses antiseizure therapies and care for multimorbidities, is determined both by epilepsy syndrome and aetiology. Identification of the underlying aetiology enables the development of precision medicines to improve the long-term outcome of patients with these devastating diseases.
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Affiliation(s)
- Ingrid E Scheffer
- Epilepsy Research Centre, The University of Melbourne, Austin Health, Heidelberg, Victoria, Australia.
- Florey and Murdoch Children's Research Institutes, Melbourne, Victoria, Australia.
- Department of Paediatrics, The University of Melbourne, Royal Children's Hospital, Parkville, Victoria, Australia.
| | - Sameer Zuberi
- Paediatric Neurosciences Research Group, School of Health & Wellbeing, University of Glasgow, Glasgow, UK
- Paediatric Neurosciences, Royal Hospital for Children, Glasgow, UK
| | - Heather C Mefford
- Center for Paediatric Neurological Disease Research, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Renzo Guerrini
- Neuroscience Department, Children's Hospital Meyer IRCCS, Florence, Italy
- University of Florence, Florence, Italy
| | - Amy McTague
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
- Department of Neurology, Great Ormond Street Hospital, London, UK
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Gil-Nagel A, Cross JH, Devinsky O, Ceulemans B, Lagae L, Knupp K, Schoonjans AS, Ryvlin P, Thiele EA, Polega S, Lothe A, Nabbout R. Comprehensive scoping review of fenfluramine's role in managing generalized tonic-clonic seizures in developmental and epileptic encephalopathies. Epilepsia 2024; 65:2186-2199. [PMID: 39030735 DOI: 10.1111/epi.18020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 07/22/2024]
Abstract
Developmental and epileptic encephalopathies (DEEs) are characterized by pharmacoresistant seizures and developmental delay. Patients with DEEs experience multiple seizure types, including tonic-clonic seizures (TCS) that can be generalized tonic-clonic (GTCS) or focal evolving to bilateral tonic-clonic (FBTCS). Fenfluramine (FFA) has demonstrated efficacy in reduction of TCS in patients with Dravet syndrome (DS), Lennox-Gastaut syndrome (LGS), and other DEEs. Using the PRISMA-ScR (Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Review) guidelines, we performed a scoping review to describe changes in TCS in patients treated with FFA. A comprehensive search of five literature databases was conducted up to February 14, 2023. Studies were included if they reported change in GTCS or TCS (but not FBTCS) after treatment with FFA in patients with DEEs. Duplicate patients and studies with unclear efficacy data were excluded. Fourteen of 422 studies met the eligibility criteria. Data extracted and evaluated by expert clinicians identified 421 unique patients with DS (in nine studies), CDKL5 deficiency disorder, SCN8A-related disorder, LGS, SCN1B-related disorder, and other DEEs. The median percent reduction in GTCS or TCS from baseline was available in 10 studies (n = 328) and ranged from 47.2% to 100%. Following FFA treatment, 10 studies (n = 144) reported ≥50% reduction in GTCS or TCS from baseline in 72% of patients; in nine of those (n = 112), 54% and 29% of patients achieved ≥75% and 100% reduction in GTCS or TCS from baseline, respectively. Overall, this analysis highlighted improvements in GTCS or TCS frequency when patients were treated with FFA regardless of the DEE evaluated. Future studies may confirm the impact of FFA on TCS reduction and on decreased premature mortality risk (including sudden unexpected death in epilepsy), improvement in comorbidities and everyday executive function, decreased health care costs, and improvement in quality of life.
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Affiliation(s)
| | - J Helen Cross
- University College London (UCL) National Institute for Health and Care Research (NIHR) Biomedical Research Centres (BRC) Great Ormond Street Institute of Child Health, London, UK
| | - Orrin Devinsky
- New York University Langone Medical Center, New York, New York, USA
| | | | | | - Kelly Knupp
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | | | | | | | | | - Rima Nabbout
- Reference Center for Rare Epilepsies, Necker Enfants Malades Hospital, APHP, U1163 Institut Imagine, Université Paris Cité, Paris, France
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Malmberg C, Värendh M, Berling P, Charokopou M, Eklund E. Cost Effectiveness of Adding Fenfluramine to Standard of Care for Patients with Dravet Syndrome in Sweden. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2024; 22:543-554. [PMID: 38758509 DOI: 10.1007/s40258-024-00886-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/25/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVE This study evaluated, in a Swedish setting, the cost effectiveness of fenfluramine (FFA) as an add-on to standard of care (SoC) for reducing seizure frequency in Dravet syndrome, a severe developmental epileptic encephalopathy. METHODS Cost effectiveness of FFA+SoC compared with SoC only was evaluated using a patient-level simulation model with a lifetime horizon. Patient characteristics and treatment effects, including convulsive seizures, seizure-free days and mortality, were derived from FFA clinical trials. Resource use and costs included cost of drug acquisition, routine care and monitoring, as well as ongoing and emergency resources. Quality of life (QoL) estimates for patients and their caregivers were derived from clinical trial data. Robustness was evaluated by one-way sensitivity analysis, probabilistic sensitivity analysis and scenario analyses. RESULTS Lifetime cost of FFA+SoC was ~3 million SEK per patient compared with ~1.5 million SEK for SoC only. FFA+SoC generated 15% more QALYs than SoC only (21.2 vs 18.5 over a lifetime), resulting in an incremental cost-effectiveness ratio (ICER) of ~540,000 SEK. Moreover, FFA+SoC had a higher probability of being cost effective than SoC only from a willingness-to-pay threshold of 710,000 SEK. Results remained generally consistent across scenario analyses, with only few exceptions (exclusions of carer utility or FFA effect on sudden unexpected death in epilepsy). CONCLUSION Due to better seizure control, FFA is a clinically meaningful add-on therapy and was estimated to be a cost-effective addition to current SoC for patients with this rare disease in Sweden at a willingness-to-pay threshold of 1,000,000 SEK.
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Affiliation(s)
- Chiara Malmberg
- The Swedish Institute for Health Economics (IHE), Lund, Sweden.
| | - Magnus Värendh
- The Swedish Institute for Health Economics (IHE), Lund, Sweden
| | | | | | - Erik Eklund
- Clinical Sciences, Pediatric Neurology, Lund University, Lund, Sweden
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Daniłowska K, Picheta N, Żyła D, Piekarz J, Zych K, Gil-Kulik P. New Pharmacological Therapies in the Treatment of Epilepsy in the Pediatric Population. J Clin Med 2024; 13:3567. [PMID: 38930098 PMCID: PMC11204858 DOI: 10.3390/jcm13123567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 06/14/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024] Open
Abstract
Epilepsy is a disorder characterized by abnormal brain neuron activity, predisposing individuals to seizures. The International League Against Epilepsy (ILAE) categorizes epilepsy into the following groups: focal, generalized, generalized and focal, and unknown. Infants are the most vulnerable pediatric group to the condition, with the cause of epilepsy development being attributed to congenital brain developmental defects, white matter damage, intraventricular hemorrhage, perinatal hypoxic-ischemic injury, perinatal stroke, or genetic factors such as mutations in the Sodium Channel Protein Type 1 Subunit Alpha (SCN1A) gene. Due to the risks associated with this condition, we have investigated how the latest pharmacological treatments for epilepsy in children impact the reduction or complete elimination of seizures. We reviewed literature from 2018 to 2024, focusing on the age group from 1 month to 18 years old, with some studies including this age group as well as older individuals. The significance of this review is to present and compile research findings on the latest antiseizure drugs (ASDs), their effectiveness, dosing, and adverse effects in the pediatric population, which can contribute to selecting the best drug for a particular patient. The medications described in this review have shown significant efficacy and safety in the studied patient group, outweighing the observed adverse effects. The main aim of this review is to provide a comprehensive summary of the current state of knowledge regarding the newest pharmacotherapy for childhood epilepsy.
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Affiliation(s)
- Karolina Daniłowska
- Student’s Scientific Society of Clinical Genetics, Medical University of Lublin, 20-080 Lublin, Poland; (K.D.); (N.P.); (D.Ż.); (J.P.); (K.Z.)
| | - Natalia Picheta
- Student’s Scientific Society of Clinical Genetics, Medical University of Lublin, 20-080 Lublin, Poland; (K.D.); (N.P.); (D.Ż.); (J.P.); (K.Z.)
| | - Dominika Żyła
- Student’s Scientific Society of Clinical Genetics, Medical University of Lublin, 20-080 Lublin, Poland; (K.D.); (N.P.); (D.Ż.); (J.P.); (K.Z.)
| | - Julia Piekarz
- Student’s Scientific Society of Clinical Genetics, Medical University of Lublin, 20-080 Lublin, Poland; (K.D.); (N.P.); (D.Ż.); (J.P.); (K.Z.)
| | - Katarzyna Zych
- Student’s Scientific Society of Clinical Genetics, Medical University of Lublin, 20-080 Lublin, Poland; (K.D.); (N.P.); (D.Ż.); (J.P.); (K.Z.)
| | - Paulina Gil-Kulik
- Department of Clinical Genetics, Medical University of Lublin, 20-080 Lublin, Poland
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Guo J, Min D, Farrell EK, Zhou Y, Faingold CL, Cotten JF, Feng HJ. Enhancing the action of serotonin by three different mechanisms prevents spontaneous seizure-induced mortality in Dravet mice. Epilepsia 2024; 65:1791-1800. [PMID: 38593237 PMCID: PMC11166528 DOI: 10.1111/epi.17966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 03/12/2024] [Accepted: 03/13/2024] [Indexed: 04/11/2024]
Abstract
OBJECTIVE Sudden unexpected death in epilepsy (SUDEP) is an underestimated complication of epilepsy. Previous studies have demonstrated that enhancement of serotonergic neurotransmission suppresses seizure-induced sudden death in evoked seizure models. However, it is unclear whether elevated serotonin (5-HT) function will prevent spontaneous seizure-induced mortality (SSIM), which is characteristic of human SUDEP. We examined the effects of 5-HT-enhancing agents that act by three different pharmacological mechanisms on SSIM in Dravet mice, which exhibit a high incidence of SUDEP, modeling human Dravet syndrome. METHODS Dravet mice of both sexes were evaluated for spontaneous seizure characterization and changes in SSIM incidence induced by agents that enhance 5-HT-mediated neurotransmission. Fluoxetine (a selective 5-HT reuptake inhibitor), fenfluramine (a 5-HT releaser and agonist), SR 57227 (a specific 5-HT3 receptor agonist), or saline (vehicle) was intraperitoneally administered over an 8-day period in Dravet mice, and the effect of these treatments on SSIM was examined. RESULTS Spontaneous seizures in Dravet mice generally progressed from wild running to tonic seizures with or without SSIM. Fluoxetine at 30 mg/kg, but not at 20 or 5 mg/kg, significantly reduced SSIM compared with the vehicle control. Fenfluramine at 1-10 mg/kg, but not .2 mg/kg, fully protected Dravet mice from SSIM, with all mice surviving. Compared with the vehicle control, SR 57227 at 20 mg/kg, but not at 10 or 5 mg/kg, significantly lowered SSIM. The effect of these drugs on SSIM was independent of sex. SIGNIFICANCE Our data demonstrate that elevating serotonergic function by fluoxetine, fenfluramine, or SR 57227 significantly reduces or eliminates SSIM in Dravet mice in a sex-independent manner. These findings suggest that deficits in serotonergic neurotransmission likely play an important role in the pathogenesis of SSIM, and fluoxetine and fenfluramine, which are US Food and Drug Administration-approved medications, may potentially prevent SUDEP in at-risk patients.
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Affiliation(s)
- Jialing Guo
- National Health Commission Key Laboratory of Birth Defect Research and Prevention, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, Hunan, China
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Anesthesia, Harvard Medical School, Boston, MA, USA
| | - Daniel Min
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Emory K. Farrell
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Yupeng Zhou
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Carl L. Faingold
- Department of Pharmacology, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Joseph F. Cotten
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Anesthesia, Harvard Medical School, Boston, MA, USA
| | - Hua-Jun Feng
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Anesthesia, Harvard Medical School, Boston, MA, USA
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Pietrafusa N, Trivisano M, Casellato S, Correale C, Cappelletti S, De Liso P, Onida I, Sotgiu S, Butera A, Specchio N, Vigevano F. Fenfluramine below the age of 2 years in Dravet syndrome: What about safety and efficacy? Epilepsia 2024; 65:e7-e13. [PMID: 38065833 DOI: 10.1111/epi.17854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/06/2023] [Accepted: 12/07/2023] [Indexed: 12/22/2023]
Abstract
Dravet syndrome (DS) is a rare developmental and epileptic encephalopathy. Infants with DS are especially vulnerable to the detrimental effects of prolonged and frequent seizures on development. Fenfluramine (FFA) is approved for the treatment of DS in patients aged 2 years and older. This study aims to evaluate the safety and efficacy of FFA in patients with DS younger than 2 years. We analyzed safety, tolerability, seizure, and neuropsychological outcome in a real-world setting. Developmental profile was investigated using Griffiths Mental Development Scales (GMDS). Five patients received FFA at a mean age of 14.9 months (9.6-18.6). Median follow-up was 13 months (interquartile range [IQR] = 12.9-24.4). All patients showed good tolerance to FFA. No significant variation of body mass index or echocardiographic issue was observed. Monthly median convulsive seizure frequency (MCSF) was 1.71 (IQR = 1.56-3.27) at the 6-month baseline period and .92 (IQR = .43-1.28) at last follow-up, with a median 54.43 (IQR = 40.91-60.83) percentage reduction in MCSF. Two of five patients had a performance improvement on GMDS subscales. Overall, the use of FFA below the age of 2 years in our small sample of patients was safe and represents a promising opportunity for seizure control and for protection of the neurodevelopmental outcome.
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Affiliation(s)
- Nicola Pietrafusa
- Neurology, Epilepsy, and Movement Disorders Unit, Full Member of European Reference Network EpiCARE, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Marina Trivisano
- Neurology, Epilepsy, and Movement Disorders Unit, Full Member of European Reference Network EpiCARE, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Susanna Casellato
- Diagnosis and Treatment of Developmental Epilepsy, Child Neuropsychiatry Unit, Women and Children Department, AOU Sassari, Sassari, Italy
| | - Cinzia Correale
- Neurology, Epilepsy, and Movement Disorders Unit, Full Member of European Reference Network EpiCARE, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Simona Cappelletti
- Neurology, Epilepsy, and Movement Disorders Unit, Full Member of European Reference Network EpiCARE, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paola De Liso
- Neurology, Epilepsy, and Movement Disorders Unit, Full Member of European Reference Network EpiCARE, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Ilaria Onida
- Diagnosis and Treatment of Developmental Epilepsy, Child Neuropsychiatry Unit, Women and Children Department, AOU Sassari, Sassari, Italy
| | - Stefano Sotgiu
- Diagnosis and Treatment of Developmental Epilepsy, Child Neuropsychiatry Unit, Women and Children Department, AOU Sassari, Sassari, Italy
| | - Ambra Butera
- Neurology and Child Psychiatry Unit, Gaetano Barresi Department of Human Pathology of Adulthood and Development, University of Messina, Messina, Italy
| | - Nicola Specchio
- Neurology, Epilepsy, and Movement Disorders Unit, Full Member of European Reference Network EpiCARE, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Federico Vigevano
- Neurological Sciences and Rehabilitation Medicine Scientific Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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10
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Fan HC, Yang MT, Lin LC, Chiang KL, Chen CM. Clinical and Genetic Features of Dravet Syndrome: A Prime Example of the Role of Precision Medicine in Genetic Epilepsy. Int J Mol Sci 2023; 25:31. [PMID: 38203200 PMCID: PMC10779156 DOI: 10.3390/ijms25010031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 12/14/2023] [Accepted: 12/17/2023] [Indexed: 01/12/2024] Open
Abstract
Dravet syndrome (DS), also known as severe myoclonic epilepsy of infancy, is a rare and drug-resistant form of developmental and epileptic encephalopathies, which is both debilitating and challenging to manage, typically arising during the first year of life, with seizures often triggered by fever, infections, or vaccinations. It is characterized by frequent and prolonged seizures, developmental delays, and various other neurological and behavioral impairments. Most cases result from pathogenic mutations in the sodium voltage-gated channel alpha subunit 1 (SCN1A) gene, which encodes a critical voltage-gated sodium channel subunit involved in neuronal excitability. Precision medicine offers significant potential for improving DS diagnosis and treatment. Early genetic testing enables timely and accurate diagnosis. Advances in our understanding of DS's underlying genetic mechanisms and neurobiology have enabled the development of targeted therapies, such as gene therapy, offering more effective and less invasive treatment options for patients with DS. Targeted and gene therapies provide hope for more effective and personalized treatments. However, research into novel approaches remains in its early stages, and their clinical application remains to be seen. This review addresses the current understanding of clinical DS features, genetic involvement in DS development, and outcomes of novel DS therapies.
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Affiliation(s)
- Hueng-Chuen Fan
- Department of Pediatrics, Tungs’ Taichung Metroharbor Hospital, Wuchi, Taichung 435, Taiwan;
- Department of Rehabilitation, Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli 356, Taiwan
- Department of Life Sciences, Agricultural Biotechnology Center, National Chung Hsing University, Taichung 402, Taiwan
| | - Ming-Tao Yang
- Department of Pediatrics, Far Eastern Memorial Hospital, New Taipei City 220, Taiwan;
- Department of Chemical Engineering and Materials Science, Yuan Ze University, Taoyuan 320, Taiwan
| | - Lung-Chang Lin
- Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan;
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Kuo-Liang Chiang
- Department of Pediatric Neurology, Kuang-Tien General Hospital, Taichung 433, Taiwan;
- Department of Nutrition, Hungkuang University, Taichung 433, Taiwan
| | - Chuan-Mu Chen
- Department of Life Sciences, Agricultural Biotechnology Center, National Chung Hsing University, Taichung 402, Taiwan
- The iEGG and Animal Biotechnology Center, and Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung 402, Taiwan
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11
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Strzelczyk A, Lagae L, Wilmshurst JM, Brunklaus A, Striano P, Rosenow F, Schubert‐Bast S. Dravet syndrome: A systematic literature review of the illness burden. Epilepsia Open 2023; 8:1256-1270. [PMID: 37750463 PMCID: PMC10690674 DOI: 10.1002/epi4.12832] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/22/2023] [Indexed: 09/27/2023] Open
Abstract
We performed a systematic literature review and narrative synthesis according to a pre-registered protocol (Prospero: CRD42022376561) to identify the evidence associated with the burden of illness in Dravet syndrome (DS), a developmental and epileptic encephalopathy characterized by drug-resistant epilepsy with neurocognitive and neurobehavioral impairment. We searched MEDLINE, Embase, and APA PsychInfo, Cochrane's database of systematic reviews, and Epistemonikos from inception to June 2022. Non-interventional studies reporting on epidemiology (incidence, prevalence, and mortality), patient and caregiver health-related quality of life (HRQoL), direct and indirect costs and healthcare resource utilization were eligible. Two reviewers independently carried out the screening. Pre-specified data were extracted and a narrative synthesis was conducted. Overall, 49 studies met the inclusion criteria. The incidence varied from 1:15 400-1:40 900, and the prevalence varied from 1.5 per 100 000 to 6.5 per 100 000. Mortality was reported in 3.7%-20.8% of DS patients, most commonly due to sudden unexpected death in epilepsy and status epilepticus. Patient HRQoL, assessed by caregivers, was lower than in non-DS epilepsy patients; mean scores (0 [worst] to 100/1 [best]) were 62.1 for the Kiddy KINDL/Kid-KINDL, 46.5-54.7 for the PedsQL and 0.42 for the EQ-5D-5L. Caregivers, especially mothers, were severely affected, with impacts on their time, energy, sleep, career, and finances, while siblings were also affected. Symptoms of depression were reported in 47%-70% of caregivers. Mean total direct costs were high across all studies, ranging from $11 048 to $77 914 per patient per year (PPPY), with inpatient admissions being a key cost driver across most studies. Mean costs related to lost productivity were only reported in three publications, ranging from approximately $19 000 to $20 000 PPPY ($17 596 for mothers vs $1564 for fathers). High seizure burden was associated with higher resource utilization, costs and poorer HRQoL. The burden of DS on patients, caregivers, the healthcare system, and society is profound, reflecting the severe nature of the syndrome. Future studies will be able to assess the impact that newly approved therapies have on reducing the burden of DS.
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Affiliation(s)
- Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine‐Main, Center of Neurology and NeurosurgeryGoethe‐University and University Hospital FrankfurtFrankfurt am MainGermany
- LOEWE Center for Personalized and Translational Epilepsy Research (CePTER)Goethe‐University FrankfurtFrankfurt am MainGermany
| | - Lieven Lagae
- Department of Development and RegenerationUniversity Hospitals KU LeuvenLeuvenBelgium
| | - Jo M Wilmshurst
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, Neuroscience InstituteUniversity of Cape TownCape TownSouth Africa
| | - Andreas Brunklaus
- Paediatric Neurosciences Research GroupRoyal Hospital for ChildrenGlasgowUK
- School of Health and WellbeingUniversity of GlasgowGlasgowUK
| | - Pasquale Striano
- IRCCS ‘G. Gaslini’ InstituteGenovaItaly
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child HealthUniversity of GenoaGenovaItaly
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine‐Main, Center of Neurology and NeurosurgeryGoethe‐University and University Hospital FrankfurtFrankfurt am MainGermany
- LOEWE Center for Personalized and Translational Epilepsy Research (CePTER)Goethe‐University FrankfurtFrankfurt am MainGermany
| | - Susanne Schubert‐Bast
- Epilepsy Center Frankfurt Rhine‐Main, Center of Neurology and NeurosurgeryGoethe‐University and University Hospital FrankfurtFrankfurt am MainGermany
- LOEWE Center for Personalized and Translational Epilepsy Research (CePTER)Goethe‐University FrankfurtFrankfurt am MainGermany
- Department of NeuropediatricsGoethe‐University and University Hospital FrankfurtFrankfurt am MainGermany
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12
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Barbour K, Tian N, Yozawitz EG, Wolf S, McGoldrick PE, Sands TT, Nelson A, Basma N, Grinspan ZM. Creating rare epilepsy cohorts using keyword search in electronic health records. Epilepsia 2023; 64:2738-2749. [PMID: 37498137 PMCID: PMC10984273 DOI: 10.1111/epi.17725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 07/23/2023] [Accepted: 07/24/2023] [Indexed: 07/28/2023]
Abstract
OBJECTIVE Administrative codes to identify people with rare epilepsies in electronic health records are limited. The current study evaluated the use of keyword search as an alternative method for rare epilepsy cohort creation using electronic health records data. METHODS Data included clinical notes from encounters with International Classification of Diseases, Ninth Revision (ICD-9) codes for seizures, epilepsy, and/or convulsions during 2010-2014, across six health care systems in New York City. We identified cases with rare epilepsies by searching clinical notes for keywords associated with 33 rare epilepsies. We validated cases via manual chart review. We compared the performance of keyword search to manual chart review using positive predictive value (PPV), sensitivity, and F-score. We selected an initial combination of keywords using the highest F-scores. RESULTS Data included clinical notes from 77 924 cases with ICD-9 codes for seizures, epilepsy, and/or convulsions. The all-keyword search method identified 6095 candidates, and manual chart review confirmed that 2068 (34%) had a rare epilepsy. The initial combination method identified 1862 cases with a rare epilepsy, and this method performed as follows: PPV median = .64 (interquartile range [IQR] = .50-.81, range = .20-1.00), sensitivity median = .93 (IQR = .76-1.00, range = .10-1.00), and F-score median = .71 (IQR = .63-.85, range = .18-1.00). Using this method, we identified four cohorts of rare epilepsies with over 100 individuals, including infantile spasms, Lennox-Gastaut syndrome, Rett syndrome, and tuberous sclerosis complex. We identified over 50 individuals with two rare epilepsies that do not have specific ICD-10 codes for cohort creation (epilepsy with myoclonic atonic seizures, Sturge-Weber syndrome). SIGNIFICANCE Keyword search is an effective method for cohort creation. These findings can improve identification and surveillance of individuals with rare epilepsies and promote their referral to specialty clinics, clinical research, and support groups.
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Affiliation(s)
- Kristen Barbour
- University of California San Diego, San Diego, California, USA
| | - Niu Tian
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Elissa G Yozawitz
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Steven Wolf
- Boston Children's Health Physicians, Hawthorne, New York, USA
- New York Medical College, Valhalla, New York, USA
| | - Patricia E McGoldrick
- Boston Children's Health Physicians, Hawthorne, New York, USA
- New York Medical College, Valhalla, New York, USA
| | - Tristan T Sands
- Columbia University Irving Medical Center, New York, New York, USA
| | - Aaron Nelson
- New York University Langone Medical Center, New York, New York, USA
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13
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Dini G, Di Cara G, Ferrara P, Striano P, Verrotti A. Reintroducing Fenfluramine as a Treatment for Seizures: Current Knowledge, Recommendations and Gaps in Understanding. Neuropsychiatr Dis Treat 2023; 19:2013-2025. [PMID: 37790801 PMCID: PMC10543412 DOI: 10.2147/ndt.s417676] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/19/2023] [Indexed: 10/05/2023] Open
Abstract
Despite the introduction of new anti-seizure medications in recent years, approximately one-third of the epileptic population continues to experience seizures. Recently, the anti-obesity medication fenfluramine (FFA) has been successfully repurposed, and it has received approval from various regulatory agencies for the treatment of seizures associated with Dravet syndrome and Lennox-Gastaut syndrome. The potential antiseizure effects of FFA were initially observed in patients with photosensitive epilepsy in the 1980s but it was not rigorously explored as a treatment option until 30 years later. This narrative review aims to provide an overview of the historical progression of FFA's use, starting from initial clinical observations to preclinical studies and, ultimately, successful clinical trials in the field of epilepsy.
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Affiliation(s)
- Gianluca Dini
- Department of Pediatrics, University of Perugia, Perugia, Italy
| | | | - Pietro Ferrara
- Department of Pediatrics, Campus Bio-Medico University, Rome, Italy
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto “G. Gaslini”, Genoa, Italy
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14
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Abstract
Fenfluramine (Fintepla®) is an oral anti-seizure medication (ASM) with a novel mechanism of action consisting of activity in the serotonergic system coupled with positive allosteric modulation effects at sigma-1 receptors. Originally approved for use at high doses as an appetite suppressant, it was subsequently withdrawn after being linked to valvular heart disease (VHD) and pulmonary arterial hypertension (PAH), before being investigated for use at low doses as an adjunctive ASM in patients with developmental epileptic encephalopathies, including Dravet syndrome (DS) and Lennox-Gastaut syndrome (LGS) who have pharmacoresistant seizures. In clinical trials, treatment with adjunctive fenfluramine markedly reduced convulsive seizure frequency in patients with DS that were sustained for up to 3 years, and reduced drop seizure frequency in patients with LGS that were sustained for up to 1 year. Notably, fenfluramine was also associated with clinically meaningful improvements in aspects of everyday executive functioning (EF) not entirely explainable by seizure reduction alone. Furthermore, it was generally well tolerated with, importantly, no reports of VHD or PAH. Thus, adjunctive fenfluramine is a novel and effective treatment for pharmacoresistant seizures associated with DS and LGS that may also improve aspects of everyday EF in some patients.
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Affiliation(s)
- James E Frampton
- Springer Nature, Mairangi Bay, Private Bag 65901, Auckland, 0754, New Zealand.
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15
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Malar DS, Thitilertdecha P, Ruckvongacheep KS, Brimson S, Tencomnao T, Brimson JM. Targeting Sigma Receptors for the Treatment of Neurodegenerative and Neurodevelopmental Disorders. CNS Drugs 2023; 37:399-440. [PMID: 37166702 PMCID: PMC10173947 DOI: 10.1007/s40263-023-01007-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/18/2023] [Indexed: 05/12/2023]
Abstract
The sigma-1 receptor is a 223 amino acid-long protein with a recently identified structure. The sigma-2 receptor is a genetically unrelated protein with a similarly shaped binding pocket and acts to influence cellular activities similar to the sigma-1 receptor. Both proteins are highly expressed in neuronal tissues. As such, they have become targets for treating neurological diseases, including Alzheimer's disease (AD), Huntington's disease (HD), Parkinson's disease (PD), multiple sclerosis (MS), Rett syndrome (RS), developmental and epileptic encephalopathies (DEE), and motor neuron disease/amyotrophic lateral sclerosis (MND/ALS). In recent years, there have been many pre-clinical and clinical studies of sigma receptor (1 and 2) ligands for treating neurological disease. Drugs such as blarcamesine, dextromethorphan and pridopidine, which have sigma-1 receptor activity as part of their pharmacological profile, are effective in treating multiple aspects of several neurological diseases. Furthermore, several sigma-2 receptor ligands are under investigation, including CT1812, rivastigmine and SAS0132. This review aims to provide a current and up-to-date analysis of the current clinical and pre-clinical data of drugs with sigma receptor activities for treating neurological disease.
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Affiliation(s)
- Dicson S Malar
- Natural Products for Neuroprotection and Anti-ageing Research Unit, Chulalongkorn University, Bangkok, Thailand
| | - Premrutai Thitilertdecha
- Siriraj Research Group in Immunobiology and Therapeutic Sciences, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kanokphorn S Ruckvongacheep
- Department of Clinical Microscopy, Faculty of Allied Health Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Sirikalaya Brimson
- Department of Clinical Microscopy, Faculty of Allied Health Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Tewin Tencomnao
- Natural Products for Neuroprotection and Anti-ageing Research Unit, Chulalongkorn University, Bangkok, Thailand
| | - James M Brimson
- Natural Products for Neuroprotection and Anti-ageing Research Unit, Chulalongkorn University, Bangkok, Thailand.
- Research, Innovation and International Affairs, Faculty of Allied Health Sciences, Chulalongkorn University, Room 409, ChulaPat-1 Building, 154 Rama 1 Road, Bangkok, 10330, Thailand.
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16
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Gao C, Pielas M, Jiao F, Mei D, Wang X, Kotulska K, Jozwiak S. Epilepsy in Dravet Syndrome—Current and Future Therapeutic Opportunities. J Clin Med 2023; 12:jcm12072532. [PMID: 37048615 PMCID: PMC10094968 DOI: 10.3390/jcm12072532] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/17/2023] [Accepted: 03/23/2023] [Indexed: 03/30/2023] Open
Abstract
Dravet Syndrome (DS) is a developmental epileptic encephalopathy characterized by drug-resistant seizures and other clinical features, including intellectual disability and behavioral, sleep, and gait problems. The pathogenesis is strongly connected to voltage-gated sodium channel dysfunction. The current consensus of seizure management in DS consists of a combination of conventional and recently approved drugs such as stiripentol, cannabidiol, and fenfluramine. Despite promising results in randomized clinical trials and extension studies, the prognosis of the developmental outcomes of patients with DS remains unfavorable. The article summarizes recent changes in the therapeutic approach to DS and discusses ongoing clinical research directions. Serotonergic agents under investigation show promising results and may replace less DS-specific medicines. The use of antisense nucleotides and gene therapy is focused not only on symptom relief but primarily addresses the underlying cause of the syndrome. Novel compounds, after expected safe and successful implementation in clinical practice, will open a new era for patients with DS. The main goal of causative treatment is to modify the natural course of the disease and provide the best neurodevelopmental outcome with minimum neurological deficit.
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17
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Nott E, Behl KE, Brambilla I, Green TE, Lucente M, Vavassori R, Watson A, Dalla Bernardina B, Hildebrand MS. Rare. The importance of research, analysis, reporting and education in 'solving' the genetic epilepsies: A perspective from the European patient advocacy group for EpiCARE. Eur J Med Genet 2023; 66:104680. [PMID: 36623768 DOI: 10.1016/j.ejmg.2022.104680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 11/14/2022] [Accepted: 12/11/2022] [Indexed: 01/09/2023]
Affiliation(s)
- E Nott
- European Patient Advocacy Group (ePAG) EpiCARE, France; Hope for Hypothalamic Hamartomas and Hope for Hypothalamic Hamartomas-UK, UK.
| | - K E Behl
- Alternating Hemiplegia of Childhood UK (AHCUK) and Alternating Hemiplegia of Childhood Federation of Europe (AHCFE), UK
| | - I Brambilla
- European Patient Advocacy Group (ePAG) EpiCARE, France; Dravet Italia Onlus; Epilepsy Research Centre, Department of Medicine, The University of Melbourne, Austin Health, Heidelberg, Victoria, 3084, Australia
| | - T E Green
- Epilepsy Research Centre, Department of Medicine, The University of Melbourne, Austin Health, Heidelberg, Victoria, 3084, Australia; Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, Victoria, 3052, Australia
| | - M Lucente
- European Patient Advocacy Group (ePAG) EpiCARE, France; Associazione Italiana GLUT1 Onlus, Italy
| | - R Vavassori
- European Patient Advocacy Group (ePAG) EpiCARE, France; International Alternating Hemiplegia of Childhood Research Consortium (IAHCRC), USA; Alternating Hemiplegia of Childhood 18+ (AHC18+ e.V.) Association, Germany
| | - A Watson
- European Patient Advocacy Group (ePAG) EpiCARE, France; Ring20 Research and Support UK, UK
| | - B Dalla Bernardina
- Dravet Italia Onlus; Research Center for Pediatric Epilepsies Verona, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Italy
| | - M S Hildebrand
- Hope for Hypothalamic Hamartomas and Hope for Hypothalamic Hamartomas-UK, UK; Epilepsy Research Centre, Department of Medicine, The University of Melbourne, Austin Health, Heidelberg, Victoria, 3084, Australia; Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, Victoria, 3052, Australia
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18
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Jensen MP, Gammaitoni AR, Salem R, Wilkie D, Lothe A, Amtmann D. Fenfluramine treatment for Dravet syndrome: Caregiver- and clinician-reported benefits on the quality of life of patients, caregivers, and families living in Germany, Spain, Italy, and the United Kingdom. Epilepsy Res 2023; 190:107091. [PMID: 36701932 DOI: 10.1016/j.eplepsyres.2023.107091] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 12/30/2022] [Accepted: 01/13/2023] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Clinical trial data and prior preliminary research indicate that fenfluramine (FFA) provides meaningful improvements in seizure-related and quality of life (QOL) outcomes for individuals with Dravet syndrome (DS), their caregivers, and their families. This study sought to replicate and extend these preliminary findings in a new sample of individuals with DS and their families who live in European countries. METHODS Study participants were European clinicians and parents caring for individuals with DS who had participated in an EU FFA Early Access Program. Participants completed one-on-one semi-structured interviews and were asked the extent to which they noticed changes in a number of the child's seizure- and non-seizure-related QOL domains after starting FFA treatment. Participants were also asked about the benefits of FFA treatment to the caregivers' lives and for the family unit. RESULTS 25 parent caregivers and 16 clinicians participated. The caregivers and clinicians reported improvements in both seizure-related (i.e., reductions in seizure activity, improvements in the frequency or type of seizure triggers and post-ictal recovery times, and improved post-seizure function) and non-seizure-related (e.g., cognition, focus, alertness, speech, academic performance, behavior, sleep, motor function) QOL domains after FFA treatment in individuals with DS. Caregivers also reported improved mood and more time for things they enjoyed, felt less overwhelmed, reported better sleep quality, and had less personal and family stress; clinicians corroborated most of these reports. All clinicians (100%) and most (96%) caregivers said they would "very likely" or "quite likely" recommend FFA to others with DS. CONCLUSIONS Real-world experience in Europe with FFA treatment is associated with meaningful improvements in many QOL domains for individuals with DS and their families; replicating findings from a previous study of DS patients and their families from the USA. Caregivers and clinicians provided specific examples of the benefits of FFA for people with DS, caregivers, and their families and are very likely to recommend FFA to others with DS.
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Affiliation(s)
- Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington, 325 Ninth Avenue, Seattle, WA 98104, USA.
| | - Arnold R Gammaitoni
- Zogenix Limited, now a part of UCB, Medical Affairs, 5858 Horton Street, Suite 455, Emeryville, CA 94608, USA.
| | - Rana Salem
- Department of Rehabilitation Medicine, University of Washington, 12360 Lake City Way, Suite 502, Seattle, WA 98125, USA.
| | - Dana Wilkie
- Department of Rehabilitation Medicine, University of Washington, 12360 Lake City Way, Suite 502, Seattle, WA 98125, USA.
| | | | - Dagmar Amtmann
- Department of Rehabilitation Medicine, University of Washington, 12360 Lake City Way, Suite 502, Seattle, WA 98125, USA.
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19
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Fenfluramine for the Treatment of Dravet Syndrome and Lennox Gastaut Syndrome: A Review. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00741-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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20
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Riva A, D'Onofrio G, Amadori E, Tripodi D, Balagura G, Iurilli V, Vari MS, Verrotti A, Striano P. Current and promising therapeutic options for Dravet syndrome. Expert Opin Pharmacother 2022; 23:1727-1736. [PMID: 36124778 DOI: 10.1080/14656566.2022.2127089] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Dravet Syndrome (DS) is a developmental and epileptic encephalopathy carrying high-level psychobehavioral burdens. Although the disease has been known for almost 4 decades, and despite significant progress in the understanding of its physiopathology and natural course, the pharmacological treatment leaves patients and caregivers with significant unmet needs. This review provides a summary of the current and promising therapeutic options for DS. AREAS COVERED PubMed and ClinicalTrials.gov were screened using 'Dravet Syndrome' OR 'DS,' AND 'pharmacotherapy,' AND 'treatments.' Randomized clinical trials, structured reviews, and meta-analyses were selected for in-human application of well-known anti-seizure medications; while in-vivo experiments on models of DS were selected to evaluate the potential of new therapeutic strategies. EXPERT OPINION The search for new pharmacological treatment options is led by the need for care and defeat of the natural course of the disease, an aspect still largely neglected by the available therapeutic strategies. Yet, the last 6 years have led to a climate of increased interest and availability of clinical trials. Particularly, gene therapy could hopefully prevent DS evolution by directly relieving the specific genetic defect, although the possibility of off-target editing, and the uneasy administration route have still largely prevented its use.
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Affiliation(s)
- Antonella Riva
- Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Gianluca D'Onofrio
- Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Elisabetta Amadori
- Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Domenico Tripodi
- Department of Medical, Oral and Biotechnological Sciences, University of Chieti, Genoa, Italy
| | - Ganna Balagura
- Department of Functional Genomics, Center for Neurogenomics and Cognitive Research (CNCR), Vrije Universiteit (VU), de Boelelaan, Amsterdam, Netherlands
| | | | - Maria Stella Vari
- Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | | | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
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21
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Wu J, Zhang L, Zhou X, Wang J, Zheng X, Hu H, Wu D. Efficacy and safety of adjunctive antiseizure medications for dravet syndrome: A systematic review and network meta-analysis. Front Pharmacol 2022; 13:980937. [PMID: 36120377 PMCID: PMC9471196 DOI: 10.3389/fphar.2022.980937] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/05/2022] [Indexed: 11/24/2022] Open
Abstract
Purpose: Recently, the U.S. Food and Drug Administration (FDA) approved stiripentol, cannabidiol, and fenfluramine to treat patients with Dravet syndrome (DS). Moreover, soticlestat was determined as a promising new drug for the treatment of DS as it has good efficacy and safety. However, the efficacy and safety of these drugs have not yet been evaluated in "head-to-head" trials. This study aimed to compare and evaluate the efficacy and safety of these adjunctive antiseizure medications in the treatment of DS. Methods: We searched in PubMed, Embase, Cochrane Library, and Web of Science databases for randomized controlled trials (RCTs) and open-label extension (OLE) studies in patients with DS. We performed a random-effect meta-analysis of OLE studies and a network meta-analysis for RCTs to evaluate the efficacy and safety of antiseizure medications in the treatment of DS. Primary efficacy outcomes were defined as a ≥50% reduction in seizure frequency compared with baseline. Furthermore, safety evaluation indicators were defined as the incidence of adverse events (AEs) and serious adverse events (SAEs) during treatment. Relative ranking was assessed using the surface under the cumulative ranking curve (SUCRA) probabilities. Results: Seven RCTs involving four antiseizure medications (stiripentol, cannabidiol, fenfluramine, and soticlestat) and a total of 634 patients were included in the analysis. According to the SUCRA results, all four drugs significantly reduced the frequency of seizures compared with the placebo. Soticlestat was the most likely to reduce seizure frequency by ≥50% compared to the baseline [risk ratio (RR): 19.32; 95% confidence interval (CI): 1.20-311.40], followed by stiripentol and fenfluramine. Stiripentol was ranked highest for the near percentage reduction in the seizure rate from baseline [RR: 12.33; 95% CI: 1.71-89.17] and the occurrence of any treatment-emergent adverse events [RR: 3.73; 95% CI: 1.65-8.43] and serious adverse events [RR: 4.76; 95% CI: 0.61-37.28]. A total of ten OLE studies containing 1,121 patients were included in our study. According to the results of the meta-analysis, the order of probability of reducing seizure frequency by ≥50% was fenfluramine (0.715, 95% CI: 0.621-0.808), stiripentol (0.604, 95% CI: 0.502-0.706), cannabidiol (0.448, 95% CI: 0.403-0.493). And the probability of occurrence of AEs is ranked as fenfluramine(0.832, 95% CI: 0.795-0.869), cannabidiol (0.825, 95% CI:0.701-0.950), stiripentol (0.823, 95% CI: 0.707-0.938), soticlestat (0.688, 95% CI: 0.413-0.890). Conclusion: According to the results of indirect comparison of efficacy and safety, cannabidiol is slightly inferior to the other three antiseizure medications in terms of efficacy and safety. Soticlestat, fenfluramine, and stripentol may have little difference in efficacy, but soticlestat and fenfluramine are safer. Soticlestat is probably the best adjunctive antiseizure medication, followed by fenfluramine. This conclusion is consistent with the comparison of long-term efficacy and safety.
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Affiliation(s)
| | | | | | | | | | - Hankun Hu
- Department of Pharmacy, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Dongfang Wu
- Department of Pharmacy, Zhongnan Hospital of Wuhan University, Wuhan, China
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22
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Guerrini R, Specchio N, Aledo‐Serrano Á, Pringsheim M, Darra F, Mayer T, Gil‐Nagel A, Polster T, Zuberi SM, Lothe A, Gammaitoni A, Strzelczyk A. An examination of the efficacy and safety of fenfluramine in adults, children, and adolescents with Dravet syndrome in a real-world practice setting: A report from the Fenfluramine European Early Access Program. Epilepsia Open 2022; 7:578-587. [PMID: 35801621 PMCID: PMC9712464 DOI: 10.1002/epi4.12624] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/03/2022] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To examine the efficacy and safety of fenfluramine in patients with Dravet syndrome (DS) in three age groups: <6, 6-17, and ≥18 years old, treated in a real-world setting. METHODS Patients with DS were treated with fenfluramine in the European Union Early Access Program (EAP). Following a 28-day baseline period to establish the pretreatment monthly convulsive seizure frequency (MCSF), fenfluramine was started at a dose chosen by the treating physician and gradually titrated based on efficacy and tolerability up to a maximum of 0.7 mg/kg/day. Seizure incidence was recorded in a written diary, and adverse events (AEs) were reported at each patient visit. Cardiovascular safety was assessed by transthoracic echocardiography before treatment started and at least every 6 months thereafter. RESULTS A total of 149 patients have enrolled in the EAP and 63 were <6 years old, 62 were 6-17 years old, and 24 were ≥18 years old. After 3 months of treatment 62%, 53%, and 50% of patients demonstrated ≥75% reduction in MCSF in the <6, 6-17, and ≥18-year-old groups, respectively. This pattern of response was sustained through 12 months of treatment with 55%, 46%, and 80% of the <6, 6-17, and ≥18-year-old groups, respectively, experiencing a ≥75% reduction in MCSF. Most common AEs were loss of appetite (21%) and somnolence (16%). No valvular heart disease or pulmonary artery hypertension was observed. SIGNIFICANCE The magnitude, consistency, and durability of the response to add-on fenfluramine is consistent across age groups in patients with Dravet syndrome.
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Affiliation(s)
- Renzo Guerrini
- Children's Hospital A MeyerUniversity of Florence, Full Member of European Reference Network on Rare and Complex Epilepsies EpiCAREFlorenceItaly
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of NeuroscienceBambino Gesù Children's Hospital IRCCS, Full Member of European Reference Network on Rare and Complex Epilepsies EpiCARERomeItaly
| | - Ángel Aledo‐Serrano
- Epilepsy Program, Department of NeurologyHospital Ruber InternacionalMadridSpain
| | - Milka Pringsheim
- Clinic for Neuropediatrics and Neurorehabilitation, Epilepsy Center for Children and AdolescentsSchön KlinikVogtareuthGermany,Department for Congenital Heart Disease and Pediatric CardiologyGerman Heart CenterMunichGermany,Research Institute for Rehabilitation, Transition and PalliationParacelsus Medical UniversitySalzburgAustria
| | - Francesca Darra
- Child Neuropsychiatry, Department of Surgical Sciences, Dentistry, Gynecology and PediatricsUniversity of Verona, Full Member of European Reference Network on Rare and Complex Epilepsies EpiCAREVeronaItaly
| | - Thomas Mayer
- Epilepsy Center KleinwachauDresden‐RadebergGermany
| | - Antonio Gil‐Nagel
- Epilepsy Program, Department of NeurologyHospital Ruber InternacionalMadridSpain
| | - Tilman Polster
- Krankenhaus Mara – Bethel Epilepsy Centre, Department of Epileptology, Medical SchoolBielefeld UniversityBielefeldGermany
| | - Sameer M. Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children & Institute of Health & WellbeingUniversity of GlasgowGlasgowUK
| | | | | | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine‐Main and Department of NeurologyGoethe‐University FrankfurtFrankfurt am MainGermany
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23
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Fenfluramine treatment for dravet syndrome: Real-world benefits on quality of life from the caregiver perspective. Epilepsy Res 2022; 185:106976. [PMID: 35843016 DOI: 10.1016/j.eplepsyres.2022.106976] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/16/2022] [Accepted: 07/05/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Prior research has demonstrated durable and profound reductions in seizure frequency and improvements in executive functions in individuals with Dravet syndrome (DS) who are treated with fenfluramine (FFA). This study aimed to understand the benefits of FFA from the perspective of the patients' caregivers. METHODS Caregivers for a child with DS participated in semi-structured interviews to discuss the benefits of FFA treatment on the child with DS, the caregiver, and the family. RESULTS 65 caregivers participated. Patients were between 2 and 33 years old and had been treated with FFA for an average of 22.7 months. The most commonly reported seizure-related benefits (> 50 % of participants) of FFA treatment included a reduction in seizure activity, fewer seizure triggers, and shorter post-ictal recovery. The most common quality of life (QOL) benefits in patients included improvements in cognitive function, alertness, and academic performance. In addition, the caregivers reported improvements in their sleep quality (74 %) and that they felt less overwhelmed (72 %) and stressed (69 %) after their children began FFA treatment. Many caregivers also reported improved relationships between the child with DS and their siblings (52 %). CONCLUSIONS The study found that FFA treatment is associated with meaningful improvement in a large number of QOL domains both for the people with DS who received FFA and their families.
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24
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Gil-Nagel A, Falip M, Sánchez-Carpintero R, Abad-Sazatornil MR, Poveda JL, Aibar JÁ, Cardenal-Muñoz E, Aras LM, Sánchez R, Sancho-López A, Trillo-Mata JL, Torrejón M, Gil A. The contribution of fenfluramine to the treatment of Dravet syndrome in Spain through Multi-Criteria Decision Analysis. Epilepsy Behav 2022; 132:108711. [PMID: 35588562 DOI: 10.1016/j.yebeh.2022.108711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/07/2022] [Accepted: 04/16/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Dravet Syndrome (DS) is a severe, developmental epileptic encephalopathy (DEE) that begins in infancy and is characterized by pharmaco-resistant epilepsy and neurodevelopmental delay. Despite available antiseizure medications (ASMs), there is a need for new therapeutic options with greater efficacy in reducing seizure frequency and with adequate safety and tolerability profiles. Fenfluramine is a new ASM for the treatment of seizures associated with DS as add-on therapy to other ASMs for patients aged 2 years and older. Fenfluramine decreases seizure frequency, prolongs periods of seizure freedom potentially helping to reduce risk of Sudden Unexpected Death in Epilepsy (SUDEP) and improves patient cognitive abilities positively impacting on patients' Quality of Life (QoL). Reflective Multi-Criteria Decision Analysis (MCDA) methodology allows to determine what represents value in a given indication considering all relevant criteria for healthcare decision-making in a transparent and systematic manner from the perspective of relevant stakeholders. The aim of this study was to determine the relative value contribution of fenfluramine for the treatment of DS in Spain using MCDA. METHOD A literature review was performed to populate an adapted a MCDA framework for orphan-drug evaluation in Spain. A panel of ten Spanish experts, including neurologists, hospital pharmacists, patient representatives and decision-makers, scored four comparative evidence matrices. Results were analyzed and discussed in a group meeting through reflective MCDA discussion methodology. RESULTS Dravet syndrome is considered a severe, rare disease with significant unmet needs. Fenfluramine is perceived to have a higher efficacy profile than all available alternatives, with a better safety profile than stiripentol and topiramate and to provide improved QoL versus studied alternatives. Fenfluramine results in lower other medical costs in comparison with stiripentol and clobazam. Participants perceived that fenfluramine could lead to indirect costs savings compared to available alternatives due to its efficacy in controlling seizures. Overall, fenfluramine's therapeutic impact on patients with DS is considered high and supported by high-quality evidence. CONCLUSIONS Based on reflective MCDA, fenfluramine is considered to add greater benefit in terms of efficacy, safety and QoL when compared with available ASMs.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Alicia Gil
- Omakase Consulting S.L., Barcelona, Spain.
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25
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Specchio N, Pietrafusa N, Perucca E, Cross JH. New paradigms for the treatment of pediatric monogenic epilepsies: Progressing toward precision medicine. Epilepsy Behav 2022; 131:107961. [PMID: 33867301 DOI: 10.1016/j.yebeh.2021.107961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 12/25/2022]
Abstract
Despite the availability of 28 antiseizure medications (ASMs), one-third of people with epilepsy fail to achieve sustained freedom from seizures. Clinical outcome is even poorer for children with developmental and epileptic encephalopathies (DEEs), many of which are due to single-gene mutations. Discovery of causative genes, however, has paved the way to understanding the molecular mechanism underlying these epilepsies, and to the rational application, or development, of precision treatments aimed at correcting the specific functional defects or their consequences. This article provides an overview of current progress toward precision medicine (PM) in the management of monogenic pediatric epilepsies, by focusing on four different scenarios, namely (a) rational selection of ASMs targeting specifically the underlying pathogenetic mechanisms; (b) development of targeted therapies based on novel molecules; (c) use of dietary treatments or food constituents aimed at correcting specific metabolic defects; and (d) repurposing of medications originally approved for other indications. This article is part of the Special Issue "Severe Infantile Epilepsies".
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Affiliation(s)
- Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network EpiCARE, Rome, Italy.
| | - Nicola Pietrafusa
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network EpiCARE, Rome, Italy
| | - Emilio Perucca
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - J Helen Cross
- UCL NIHR BRC Great Ormond Street Institute of Child Health and Great Ormond Street Hospital for Children, London, UK
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26
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Dini G, Tulli E, Dell’Isola GB, Mencaroni E, Di Cara G, Striano P, Verrotti A. Improving Therapy of Pharmacoresistant Epilepsies: The Role of Fenfluramine. Front Pharmacol 2022; 13:832929. [PMID: 35668937 PMCID: PMC9164301 DOI: 10.3389/fphar.2022.832929] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 04/29/2022] [Indexed: 01/24/2023] Open
Abstract
Epilepsy is among the most common neurological chronic disorders, with a prevalence of 0.5-1%. Despite the introduction of new antiepileptic drugs during recent years, about one third of the epileptic population remain drug-resistant. Hence, especially in the pediatric population limited by different pharmacokinetics and pharmacodynamics and by ethical and regulatory issues it is needed to identify new therapeutic resources. New molecules initially used with other therapeutic indications, such as fenfluramine, are being considered for the treatment of pharmacoresistant epilepsies, including Dravet Syndrome (DS) and Lennox-Gastaut Syndrome (LGS). Drug-refractory seizures are a hallmark of both these conditions and their treatment remains a major challenge. Fenfluramine is an amphetamine derivative that was previously approved as a weight loss drug and later withdrawn when major cardiac adverse events were reported. However, a new role of fenfluramine has emerged in recent years. Indeed, fenfluramine has proved to be a promising antiepileptic drug with a favorable risk-benefit profile for the treatment of DS, LGS and possibly other drug-resistant epileptic syndromes. The mechanism by which fenfluramine provide an antiepileptic action is not fully understood but it seems to go beyond its pro-serotoninergic activity. This review aims to provide a comprehensive analysis of the literature, including ongoing trials, regarding the efficacy and safety of fenfluramine as adjunctive treatment of pharmacoresistant epilepsies.
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Affiliation(s)
- Gianluca Dini
- Department of Pediatrics, University of Perugia, Genoa, Italy,*Correspondence: Gianluca Dini,
| | - Eleonora Tulli
- Department of Pediatrics, University of Perugia, Genoa, Italy
| | | | | | | | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, IRCCS “G. Gaslini” Institute, Genoa, Italy,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
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27
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Peacock DJSJ, Yoneda JRK, Siever JE, Vis-Dunbar M, Boelman C. Movement Disorders Secondary to Novel Antiseizure Medications in Pediatric Populations: A Systematic Review and Meta-analysis of Risk. J Child Neurol 2022; 37:524-533. [PMID: 35392704 PMCID: PMC9160953 DOI: 10.1177/08830738221089742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 02/15/2022] [Accepted: 03/06/2022] [Indexed: 11/26/2022]
Abstract
Novel antiseizure medications are thought to be safer than their conventional counterparts, though no dedicated analysis of movement disorder risk among pediatric populations using novel antiseizure medications has been completed. We report a systematic review with meta-analysis describing the relationship between novel antiseizure medications and movement disorders in pediatrics.MEDLINE, EMBASE, and the World Health Organization's International Clinical Trials Registry Platform were searched up to October 2020 for randomized controlled trials investigating novel antiseizure medications in pediatric populations. Antiseizure medications included lacosamide, perampanel, eslicarbazepine, rufinamide, fenfluramine, cannabidiol, and brivaracetam. Outcomes were pooled using random effects models; risk difference (RD) and 95% confidence intervals (CIs) were calculated.Twenty-three studies were selected from 1690 nonredundant manuscripts (n = 1912 total). There was a significantly increased risk of movement disorders associated with perampanel (RD 0.07, 95% CI 0.01-0.13; n = 133), though only 1 relevant trial was found. No increased risk of movement disorders was found with other antiseizure medications.Our findings indicate most novel antiseizure medications are safe to use in pediatric populations with respect to movement disorders. However, findings were limited by quality of adverse event reporting.
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Affiliation(s)
- Dakota J. S. J. Peacock
- Division of Neurology, Department of Pediatrics, BC Children’s Hospital, Vancouver, British Columbia, Canada
- Division of Neurology, Department of Pediatrics, Faculty of
Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Joshua R. K. Yoneda
- Southern Medical Program, University of British Columbia, Kelowna,
British Columbia, Canada
| | - Jodi E. Siever
- Southern Medical Program, University of British Columbia, Kelowna,
British Columbia, Canada
| | - Mathew Vis-Dunbar
- Southern Medical Program, University of British Columbia, Kelowna,
British Columbia, Canada
| | - Cyrus Boelman
- Division of Neurology, Department of Pediatrics, BC Children’s Hospital, Vancouver, British Columbia, Canada
- Division of Neurology, Department of Pediatrics, Faculty of
Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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28
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The clinical, economic, and humanistic burden of Dravet syndrome - A systematic literature review. Epilepsy Behav 2022; 130:108661. [PMID: 35334258 DOI: 10.1016/j.yebeh.2022.108661] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 02/22/2022] [Accepted: 03/03/2022] [Indexed: 11/22/2022]
Abstract
Dravet syndrome (DS) is a developmental and epileptic encephalopathy with evolving disease course as individuals age. In recent years, the treatment landscape of DS has changed considerably, and a comprehensive systematic review of the contemporary literature is lacking. Here we synthesized published evidence on the occurrence of clinical impacts by age, the economic and humanistic (health-related quality-of-life [HRQoL]) burden, and health state utility. We provide an evidence-based, contemporary visualization of the clinical manifestations, highlighting that DS is not limited to seizures; non-seizure manifestations appear early in life and increase over time, contributing significantly to the economic and humanistic burden of disease. The primary drivers of HRQoL in DS include seizure severity, cognition, and motor and behavioral problems; in turn, these directly affect caregivers through the extent of assistance required and consequent impact on activities of daily living. Unsurprisingly, costs are driven by seizure-related events, hospitalizations, and in-home medical care visits. This systematic review highlights a paucity of longitudinal data; most studies meeting inclusion criteria were cross-sectional or had short follow-up. Nonetheless, available data illustrate the substantial impact on individuals, their families, and healthcare systems and establish the need for novel therapies to address the complex spectrum of DS manifestations.
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29
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Ding J, Wang L, Li W, Wang Y, Jiang S, Xiao L, Zhu C, Hao X, Zhao J, Kong X, Wang Z, Lu G, Wang F, Sun T. Up to What Extent Does Dravet Syndrome Benefit From Neurostimulation Techniques? Front Neurol 2022; 13:843975. [PMID: 35493838 PMCID: PMC9044920 DOI: 10.3389/fneur.2022.843975] [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: 12/27/2021] [Accepted: 02/14/2022] [Indexed: 11/25/2022] Open
Abstract
Background Dravet syndrome (DS) is a refractory developmental and epileptic encephalopathy (EE) with a variety of comorbidities, including cognitive impairment, autism-like behavior, speech dysfunction, and ataxia, which can seriously affect the quality of life of patients and impose a great burden on society and their families. Currently, the pharmacological therapy is patient dependent and may work or not. Neuromodulation techniques, including vagus nerve stimulation (VNS), deep brain stimulation (DBS), transcranial magnetic stimulation (TMS), responsive neurostimulation (RNS), and chronic subthreshold cortical stimulation (CSCS), have become common adjuvant therapies for neurological diseases, but their efficacy in the treatment of DS is unknown. Methods We searched Web of Science, PubMed, and SpringerLink for all published cases related to the neuromodulation techniques of DS until January 15, 2022. The systematic review was supplemented with relevant articles from the references. The results reported by each study were summarized narratively. Results The Web of science, PubMed and SpringerLink search yielded 258 items. A total of 16 studies published between 2016 and 2021 met the final inclusion criteria. Overall, 16 articles (109 cases) were included in this study, among which fifteen (107 patients) were involved VNS, and one (2 patients) was involved DBS. After VNS implantation, seizures were reduced to ≥50% in 60 cases (56%), seizure free were found in 8 cases (7.5%). Only two DS patients received DBS treatment, and the initial outcomes of DBS implantation were unsatisfactory. The seizures significantly improved over time for both DBS patients after the addition of antiepileptic drugs. Conclusion More than half of the DS patients benefited from VNS, and VNS may be effective in the treatment of DS. However, it is important to note that VNS does not guarantee improvement of seizures, and there is a risk of infection and subsequent device failure. Although DBS is a safe and effective strategy for the treatment of refractory epilepsy, the role of DBS in DS needs further study, as the sample size was small. Thus far, there is no strong evidence for the role of DBS in DS.
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Affiliation(s)
- Jiangwei Ding
- Ningxia Key Laboratory of Cerebrocranial Disease, The Incubation Base of National Key Laboratory, Ningxia Medical University, Yinchuan, China
- Department of Neurosurgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Lei Wang
- Ningxia Key Laboratory of Cerebrocranial Disease, The Incubation Base of National Key Laboratory, Ningxia Medical University, Yinchuan, China
- Department of Neurosurgery, The First Affiliated Hospital of Xinxiang Medical University, Weihui, China
| | - Wenchao Li
- Ningxia Key Laboratory of Cerebrocranial Disease, The Incubation Base of National Key Laboratory, Ningxia Medical University, Yinchuan, China
- Department of Neurosurgery, The First Affiliated Hospital of Xinxiang Medical University, Weihui, China
| | - Yangyang Wang
- Ningxia Key Laboratory of Cerebrocranial Disease, The Incubation Base of National Key Laboratory, Ningxia Medical University, Yinchuan, China
- Department of Neurosurgery, The First Affiliated Hospital of Xinxiang Medical University, Weihui, China
| | - Shucai Jiang
- Ningxia Key Laboratory of Cerebrocranial Disease, The Incubation Base of National Key Laboratory, Ningxia Medical University, Yinchuan, China
- Department of Neurosurgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Lifei Xiao
- Ningxia Key Laboratory of Cerebrocranial Disease, The Incubation Base of National Key Laboratory, Ningxia Medical University, Yinchuan, China
- Department of Neurosurgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Changliang Zhu
- Ningxia Key Laboratory of Cerebrocranial Disease, The Incubation Base of National Key Laboratory, Ningxia Medical University, Yinchuan, China
- Department of Neurosurgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Xiaoyan Hao
- Department of Neurology, First Affiliated Hospital of Zhengzhou University, Academy of Medical Sciences of Zhengzhou University, Zhengzhou, China
| | - Jiali Zhao
- Ningxia Key Laboratory of Cerebrocranial Disease, The Incubation Base of National Key Laboratory, Ningxia Medical University, Yinchuan, China
| | - Xuerui Kong
- Ningxia Key Laboratory of Cerebrocranial Disease, The Incubation Base of National Key Laboratory, Ningxia Medical University, Yinchuan, China
| | - Ziqin Wang
- Ningxia Key Laboratory of Cerebrocranial Disease, The Incubation Base of National Key Laboratory, Ningxia Medical University, Yinchuan, China
| | - Guangyuan Lu
- Ningxia Key Laboratory of Cerebrocranial Disease, The Incubation Base of National Key Laboratory, Ningxia Medical University, Yinchuan, China
| | - Feng Wang
- Ningxia Key Laboratory of Cerebrocranial Disease, The Incubation Base of National Key Laboratory, Ningxia Medical University, Yinchuan, China
- Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tao Sun
- Ningxia Key Laboratory of Cerebrocranial Disease, The Incubation Base of National Key Laboratory, Ningxia Medical University, Yinchuan, China
- Department of Neurosurgery, General Hospital of Ningxia Medical University, Yinchuan, China
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30
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Zimmern V, Minassian B, Korff C. A Review of Targeted Therapies for Monogenic Epilepsy Syndromes. Front Neurol 2022; 13:829116. [PMID: 35250833 PMCID: PMC8891748 DOI: 10.3389/fneur.2022.829116] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 01/13/2022] [Indexed: 11/15/2022] Open
Abstract
Genetic sequencing technologies have led to an increase in the identification and characterization of monogenic epilepsy syndromes. This increase has, in turn, generated strong interest in developing “precision therapies” based on the unique molecular genetics of a given monogenic epilepsy syndrome. These therapies include diets, vitamins, cell-signaling regulators, ion channel modulators, repurposed medications, molecular chaperones, and gene therapies. In this review, we evaluate these therapies from the perspective of their clinical validity and discuss the future of these therapies for individual syndromes.
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Affiliation(s)
- Vincent Zimmern
- Division of Child Neurology, University of Texas Southwestern, Dallas, TX, United States
- *Correspondence: Vincent Zimmern
| | - Berge Minassian
- Division of Child Neurology, University of Texas Southwestern, Dallas, TX, United States
| | - Christian Korff
- Pediatric Neurology Unit, University Hospitals, Geneva, Switzerland
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31
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Sourbron J, Lagae L. Serotonin receptors in epilepsy: novel treatment targets? Epilepsia Open 2022; 7:231-246. [PMID: 35075810 PMCID: PMC9159250 DOI: 10.1002/epi4.12580] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 01/08/2022] [Accepted: 01/20/2022] [Indexed: 11/24/2022] Open
Abstract
Despite the availability of over 30 antiseizure medications (ASMs), there is no “one size fits it all,” so there is a continuing search for novel ASMs. There are divergent data demonstrating that modulation of distinct serotonin (5‐hydroxytryptamine, 5‐HT) receptors subtypes could be beneficial in the treatment of epilepsy and its comorbidities, whereas only a few ASM, such as fenfluramine (FA), act via 5‐HT. There are 14 different 5‐HT receptor subtypes, and most epilepsy studies focus on one or a few of these subtypes, using different animal models and different ligands. We reviewed the available evidence of each 5‐HT receptor subtype using MEDLINE up to July 2021. Our search included medical subject heading (MeSH) and free terms of each “5‐HT subtype” separately and its relation to “epilepsy or seizures.” Most research underlines the antiseizure activity of 5‐HT1A,1D,2A,2C,3 agonism and 5‐HT6 antagonism. Consistently, FA, which has recently been approved for the treatment of seizures in Dravet syndrome, is an agonist of 5‐HT1D,2A,2C receptors. Even though each study focused on a distinct seizure/epilepsy type and generalization of different findings could lead to false interpretations, we believe that the available preclinical and clinical studies emphasize the role of serotonergic modulation, especially stimulation, as a promising avenue in epilepsy treatment.
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Affiliation(s)
- Jo Sourbron
- Department of Development and Regeneration, Section Pediatric Neurology, University Hospital KU Leuven, Leuven, Belgium.,Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - Lieven Lagae
- Department of Development and Regeneration, Section Pediatric Neurology, University Hospital KU Leuven, Leuven, Belgium
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Strzelczyk A, Schubert-Bast S. A Practical Guide to the Treatment of Dravet Syndrome with Anti-Seizure Medication. CNS Drugs 2022; 36:217-237. [PMID: 35156171 PMCID: PMC8927048 DOI: 10.1007/s40263-022-00898-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2022] [Indexed: 01/14/2023]
Abstract
Dravet syndrome is a severe developmental and epileptic encephalopathy characterised by refractory seizures and cognitive dysfunction. The treatment is challenging, not least because the seizures are highly drug resistant, requiring multiple anti-seizure medications (ASMs), while some ASMs can exacerbate seizures. Initial treatments include the broad-spectrum ASMs valproate (VPA), and clobazam (CLB) in some regions; however, they are generally insufficient to control seizures. With this in mind, three adjunct ASMs have been approved specifically for the treatment of seizures in patients with Dravet syndrome: stiripentol (STP) in 2007 in the European Union and 2018 in the USA, cannabidiol (CBD) in 2018/2019 (in combination with CLB in the European Union) and fenfluramine (FFA) in 2020. These "add-on" therapies (mostly to VPA/CLB) are used as escalation therapies, with the choice dependent on availability in different countries, patient characteristics and caregiver preferences. Topiramate is also frequently used, with evidence of efficacy in Dravet syndrome, and there is anecdotal evidence of efficacy with bromide, which is frequently used in Germany and Japan. With a growing treatment landscape for Dravet syndrome, there can be practical challenges for clinicians, particularly with issues associated with polypharmacy. This practical guide provides an overview of these main ASMs including their indications/contraindications, mechanism of action, efficacy, safety and tolerability profile, dosage requirements, and laboratory and clinical parameters to be evaluated. Standard laboratory and clinical parameters include blood counts, liver function tests, serum concentrations of ASMs, monitoring the growth of children, as well as weight loss and acceleration of behavioural problems. Regular cardiac monitoring is also important with FFA as it has previously been associated with cases of cardiac valve disease when used in adults at high doses (up to 120 mg/day) in combination with phentermine as a therapy for obesity. Importantly, no signs of heart valve disease have been documented to date at the low doses used in patients with developmental and epileptic encephalopathies. In addition, potential drug-drug interactions and their consequences are a key consideration in everyday practice. Interactions that potentially require dosage adjustments to alleviate adverse events include the following: STP + CLB resulting in increased plasma concentrations of CLB and its active metabolite norclobazam may increase somnolence, and an interaction with STP and VPA may increase gastrointestinal adverse events. Cannabidiol has a bi-directional interaction with CLB producing an increase in plasma concentrations of 7-OH-CBD and norclobazam resulting in the potential for increased somnolence and sedation. In addition, CBD is associated with elevations of liver transaminases particularly in patients taking concomitant VPA. The interaction between FFA and STP requires a dose reduction of FFA. Furthermore, concomitant administration of VPA with topiramate has been associated with encephalopathy and/or hyperammonaemia. Finally, we briefly describe other ASMs used in Dravet syndrome, and current key clinical trials.
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Affiliation(s)
- Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany. .,LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.
| | - Susanne Schubert-Bast
- grid.7839.50000 0004 1936 9721Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528 Frankfurt am Main, Germany ,grid.7839.50000 0004 1936 9721LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany ,grid.7839.50000 0004 1936 9721Department of Neuropediatrics, Goethe-University Frankfurt, Frankfurt am Main, Germany
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Abstract
INTRODUCTION Patients with severe epilepsy are at increased risk of cardiovascular disease and arrhythmias. Although antiseizure medications (ASMs) may have indirect protective effects against cardiovascular events by reducing seizure frequency and hence sudden death in epilepsy, some of them exert cardiotoxic effects. AREAS COVERED Patients with epilepsy, mainly those with severe forms, are at higher risk of cardiac disease because their heart can have structural alterations and electrical instability as a consequence of repeated seizures. Some ASMs have direct protective effects through anti-inflammatory, antioxidant, hypotensive, and lipid-reducing properties. Antiseizure medications can also have toxic cardiac effects including both long-term consequences, such as the increased risk of atherogenesis and subsequent cardiovascular disease due to the influence on lipid profile and pro-inflammatory milieu, and immediate effects as the increased risk of potentially fatal arrhythmias due to the influence on ion channels. Sodium channel blocking ASMs may also affect cardiac sodium channels and this effect is particularly observed in subjects with genetic mutations in cardiac ion channels. Fenfluramine cause valvulopathies in obese subjects and this effect need to be evaluated in epilepsy patients. EXPERT OPINION For the selection of treatment, cardiotoxic effects of ASMs should be considered; cardiac monitoring of treatment is advisable.
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Affiliation(s)
- Gaetano Zaccara
- Department of Eidemiology, Regional Health Agency of Tuscany, Firenze, Italy
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (Sabes-asdaa), Merano-Meran, Italy
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Cardenal-Muñoz E, Auvin S, Villanueva V, Cross JH, Zuberi SM, Lagae L, Aibar JÁ. Guidance on Dravet syndrome from infant to adult care: Road map for treatment planning in Europe. Epilepsia Open 2021; 7:11-26. [PMID: 34882995 PMCID: PMC8886070 DOI: 10.1002/epi4.12569] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 11/24/2021] [Accepted: 12/02/2021] [Indexed: 12/22/2022] Open
Abstract
Dravet syndrome (DS) is a severe, rare, and complex developmental and epileptic encephalopathy affecting 1 in 16 000 live births and characterized by a drug‐resistant epilepsy, cognitive, psychomotor, and language impairment, and behavioral disorders. Evidence suggests that optimal treatment of seizures in DS may improve outcomes, even though neurodevelopmental impairments are the likely result of both the underlying genetic variant and the epilepsy. We present an updated guideline for DS diagnosis and treatment, taking into consideration care of the adult patient and nonpharmaceutical therapeutic options for this disease. This up‐to‐date guideline, which is based on an extensive review of the literature and culminates with a new treatment algorithm for DS, is a European consensus developed through a survey involving 29 European clinical experts in DS. This guideline will serve professionals in their clinical practice and, as a consequence, will benefit DS patients and their families.
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Affiliation(s)
- Elena Cardenal-Muñoz
- Dravet Syndrome Foundation Spain, Member of the EpiCARE ePAG Group, Madrid, Spain
| | - Stéphane Auvin
- APHP. Service de Neurologie Pédiatrique, Hôpital Robert Debré, Paris, France.,INSERM NeuroDiderot, Université de Paris, Paris, France.,Institut Universitaire de France (IUF), Paris, France
| | - Vicente Villanueva
- Refractory Epilepsy Unit, Hospital Universitario y Politécnico La Fe, Member of the ERN EpiCARE, Valencia, Spain
| | - J Helen Cross
- Department of Developmental Neurosciences, UCL NIHR BRC Great Ormond Street Institute of Child Health, London, UK.,Department of Neurology, Great Ormond Street Hospital for Children, Member of the ERN EpiCARE, London, UK
| | - Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Member of the ERN EpiCARE, Glasgow, UK.,Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - Lieven Lagae
- Department of Development and Regeneration, KU Leuven, Member of the ERN EpiCARE, Leuven, Belgium
| | - José Ángel Aibar
- Dravet Syndrome Foundation Spain, Member of the EpiCARE ePAG Group, Madrid, Spain
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Tupal S, Faingold CL. Serotonin 5-HT 4 receptors play a critical role in the action of fenfluramine to block seizure-induced sudden death in a mouse model of SUDEP. Epilepsy Res 2021; 177:106777. [PMID: 34601387 DOI: 10.1016/j.eplepsyres.2021.106777] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/25/2021] [Accepted: 09/21/2021] [Indexed: 11/28/2022]
Abstract
RATIONALE Our previous study showed that the recently approved anticonvulsant drug, fenfluramine, which enhances the release of serotonin (5-hydroxytryptamine, 5-HT) in the brain, prevents seizure-induced respiratory arrest (S-IRA) in the DBA/1 mouse model of sudden unexpected death in epilepsy (SUDEP). The present study examined the role of 5-HT receptor subtypes in mediating the effect of this agent by combined administration of fenfluramine with selective 5-HT receptor antagonists prior to seizure in DBA/1 mice. METHODS Fenfluramine (15 mg/kg, i.p.) was administered to primed DBA/1 mice, and audiogenic seizure (Sz) was induced 16 h later. Thirty min prior to Sz induction a selective antagonist acting on 5-HT1A, 5-HT2, 5-HT3 5-HT4, 5-HT5A, 5-HT6 or 5-HT7 receptors at a sub-toxic dose was administered, and changes in seizure-induced behaviors were evaluated. Follow-up studies examined the effect of administration of a 5-HT4 receptor agonist, BIMU 8, as well as the effect of co-administration of ineffective doses of fenfluramine and BIMU-8 on Sz behaviors. RESULTS The 5-HT4 antagonist (GR125487) was the only 5-HT receptor antagonist that was able to reverse the action of fenfluramine to block Sz and S-IRA. Treatment with the 5-HT4 receptor agonist (BIMU-8), or co-administration of ineffective doses of BIMU-8 and fenfluramine significantly reduced the incidence of S-IRA and tonic Sz in DBA/1 mice. The antagonists for 5-HT3, 5-HT5A 5-HT6, and 5-HT7 receptors did not significantly affect the action of fenfluramine. However, the 5-HT1A and the 5-HT2 antagonists enhanced the anticonvulsant effects of fenfluramine. CONCLUSIONS These findings suggest that the action of fenfluramine to prevent seizure-induced sudden death in DBA/1 mice is mediated primarily by activation of 5-HT4 receptors. These studies are the first to indicate the therapeutic potential of 5-HT4 receptor agonists either alone or in combination with fenfluramine for preventing SUDEP. Enhancement of the anticonvulsant effect of fenfluramine by 5-HT1A and 5-HT2 antagonists may involve presynaptic actions of these antagonists. Thus, the Sz and S-IRA blocking actions of fenfluramine involve complex interactions with several 5-HT receptor subtypes. These data also provide further support for the serotonin hypothesis of SUDEP.
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Affiliation(s)
- Srinivasan Tupal
- Department of Pharmacology, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Carl L Faingold
- Department of Pharmacology, Southern Illinois University School of Medicine, Springfield, IL, USA.
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Strzelczyk A, Pringsheim M, Mayer T, Polster T, Klotz KA, Muhle H, Alber M, Trollmann R, Spors H, Kluger G, Kurlemann G, Schubert-Bast S. Efficacy, tolerability, and retention of fenfluramine for the treatment of seizures in patients with Dravet syndrome: Compassionate use program in Germany. Epilepsia 2021; 62:2518-2527. [PMID: 34378197 DOI: 10.1111/epi.17034] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/09/2021] [Accepted: 07/28/2021] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Dravet syndrome (DS) is a rare but severe drug-resistant epilepsy. Before the approval of fenfluramine (FFA) for the treatment of seizures in DS, patients in Germany could receive treatment under a compassionate use program (CUP). METHODS We conducted a multicenter, retrospective, observational study to describe the efficacy, tolerability, and retention of FFA within the CUP. Patients received add-on therapy with oral FFA gradually titrated to a target dose between .13 and .7 mg/kg/day. RESULTS Overall, 78 patients with DS (median age = 8.0 years, range = 2.1-46.0; 53% female, median concomitant antiseizure medications [ASMs] = 3) were treated with FFA for a median duration of 255.5 days (range = 31-572). Responder rates (a ≥50% reduction; n = 78) and seizure-freedom rates at 3 months were 68% and 14% for total seizures, respectively, and 67% and 23% for generalized tonic-clonic seizures. Responder rates were consistent at 6 and 12 months (n = 66 and n = 43, respectively). Median seizure days per month significantly decreased from 10.0 (range = .5-30) to 3.0 (range = 0-30) in the 3-month period before and after FFA treatment (p < .001). Significantly fewer patients reported at least one episode of status epilepticus (28% vs. 14% patients before and after FFA initiation, p = .005). During FFA treatment, 35 (45%) patients were able to discontinue a concomitant ASM. At the last follow-up date, 66 (85%) patients remained on treatment with FFA. The most common adverse events were somnolence (36%), decreased appetite (22%), and ataxia (8%). Forty-eight (62%) patients were reported as having a meaningful global clinical improvement. SIGNIFICANCE In a large cohort of patients, FFA demonstrated efficacy across a range of outcomes including clinically significant reductions in convulsive seizures, and was well tolerated, providing valuable information for real-world practice.
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Affiliation(s)
- Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe University Frankfurt, Frankfurt am Main, Germany.,Center for Personalized Translational Epilepsy Research, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Milka Pringsheim
- Clinic for Neuropediatrics and Neurorehabilitation, Epilepsy Center for Children and Adolescents, Schön Clinic Vogtareuth, Vogtareuth, Germany
| | - Thomas Mayer
- Epilepsy Center Kleinwachau, Dresden-Radeberg, Germany
| | - Tilman Polster
- Department of Epileptology, Bethel Epilepsy Center, Mara Hospital, Bielefeld University, Bielefeld, Germany
| | - Kerstin A Klotz
- Department of Neuropediatrics and Muscle Disorders, Center for Pediatrics, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Berta Ottenstein Program, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Hiltrud Muhle
- Department of Neuropediatrics, Christian-Albrecht University of Kiel and University Hospital Schleswig-Holstein, Kiel, Germany
| | - Michael Alber
- Department of Neuropediatrics, University of Tübingen, Tübingen, Germany
| | - Regina Trollmann
- Department of Neuropediatrics, Friedrich-Alexander University Erlangen, Erlangen, Germany
| | - Hartwig Spors
- Department of Neuropediatrics, Justus Liebig University Giessen, Giessen, Germany
| | - Gerhard Kluger
- Clinic for Neuropediatrics and Neurorehabilitation, Epilepsy Center for Children and Adolescents, Schön Clinic Vogtareuth, Vogtareuth, Germany.,Research Institute, Rehabilitation, Transition, and Palliation, Paracelsus Medical University Salzburg, Salzburg, Austria
| | | | - Susanne Schubert-Bast
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe University Frankfurt, Frankfurt am Main, Germany.,Center for Personalized Translational Epilepsy Research, Goethe University Frankfurt, Frankfurt am Main, Germany.,Department of Neuropediatrics, Goethe University Frankfurt, Frankfurt am Main, Germany
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37
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Odi R, Invernizzi RW, Gallily T, Bialer M, Perucca E. Fenfluramine repurposing from weight loss to epilepsy: What we do and do not know. Pharmacol Ther 2021; 226:107866. [PMID: 33895186 DOI: 10.1016/j.pharmthera.2021.107866] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/26/2021] [Accepted: 04/12/2021] [Indexed: 12/21/2022]
Abstract
In 2020, racemic-fenfluramine was approved in the U.S. and Europe for the treatment of seizures associated with Dravet syndrome, through a restricted/controlled access program aimed at minimizing safety risks. Fenfluramine had been used extensively in the past as an appetite suppressant, but it was withdrawn from the market in 1997 when it was found to cause cardiac valvulopathy. Available evidence indicates that appetite suppression and cardiac valvulopathy are mediated by different serotonergic mechanisms. In particular, appetite suppression can be ascribed mainly to the enantiomers d-fenfluramine and d-norfenfluramine, the primary metabolite of d-fenfluramine, whereas cardiac valvulopathy can be ascribed mainly to d-norfenfluramine. Because of early observations of markedly improved seizure control in some forms of epilepsy, fenfluramine remained available in Belgium through a Royal Decree after 1997 for use in a clinical trial in patients with Dravet syndrome at average dosages lower than those generally prescribed for appetite suppression. More recently, double-blind placebo-controlled trials established its efficacy in the treatment of convulsive seizures associated with Dravet syndrome and of drop seizures associated with Lennox-Gastaut syndrome, at doses up to 0.7 mg/kg/day (maximum 26 mg/day). Although no cardiovascular toxicity has been associated with the use of fenfluramine in epilepsy, the number of patients exposed to date has been limited and only few patients had duration of exposure longer than 3 years. This article analyzes available evidence on the mechanisms involved in fenfluramine-induced appetite suppression, antiseizure effects and cardiovascular toxicity. Despite evidence that stimulation of 5-HT2B receptors (the main mechanism leading to cardiac valvulopathy) is not required for antiseizure activity, there are many critical gaps in understanding fenfluramine's properties which are relevant to its use in epilepsy. Particular emphasis is placed on the remarkable lack of publicly accessible information about the comparative activity of the individual enantiomers of fenfluramine and norfenfluramine in experimental models of seizures and epilepsy, and on receptors systems considered to be involved in antiseizure effects. Preliminary data suggest that l-fenfluramine retains prominent antiseizure effects in a genetic zebrafish model of Dravet syndrome. If these findings are confirmed and extended to other seizure/epilepsy models, there would be an incentive for a chiral switch from racemic-fenfluramine to l-fenfluramine, which could minimize the risk of cardiovascular toxicity and reduce the incidence of adverse effects such as loss of appetite and weight loss.
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Affiliation(s)
- Reem Odi
- Institute of Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Tamar Gallily
- Yissum Technology Transfer Company of the Hebrew University of Jerusalem, Jerusalem, Israel
| | - Meir Bialer
- Institute of Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel; David R. Bloom Center for Pharmacy, The Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Emilio Perucca
- Division of Clinical and Experimental Pharmacology, Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
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Schoonjans AS, Ceulemans B. A critical evaluation of fenfluramine hydrochloride for the treatment of Dravet syndrome. Expert Rev Neurother 2021; 22:351-364. [PMID: 33455486 DOI: 10.1080/14737175.2021.1877540] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Dravet Syndrome (DS) is a severe developmental and epileptic encephalopathy. Fenfluramine recently demonstrated to be a highly efficacious and safe treatment option for DS patients. Fenfluramine has been recently approved by the FDA and EMA and is marketed as Fintepla®.Areas covered: DS and the need for additional anticonvulsive treatment options is discussed. The results of three placebo-controlled phase III studies (1 with and 2 without stiripentol) and 2 open label (extension) studies are reviewed. All studies demonstrate a consistent and impressive seizure reduction, confirming the results of two smaller investigator-initiated trials. The mechanism of action of fenfluramine is discussed. Finally, the place of fenfluramine in the future treatment of DS is outlined.Expert opinion: Fenfluramine has a potent anticonvulsive effect in DS. Although not yet fully elucidated, the anticonvulsive mechanism of fenfluramine seems to be mainly serotonergic. Fenfluramine is generally well tolerated. A dose reduction is necessary in combination with stiripentol. Considering new competitors, efficacy seems lower for cannabidiol and is comparable with stiripentol. Preclinical studies indicate a disease specific action and possible disease modification in DS. The latter would support the use of fenfluramine above its anticonvulsive effect and needs to be further elaborated.
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Affiliation(s)
- An-Sofie Schoonjans
- Department of Pediatrics and Pediatric Neurology, Antwerp University Hospital, Edegem, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Berten Ceulemans
- Department of Pediatrics and Pediatric Neurology, Antwerp University Hospital, Edegem, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
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39
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Selvarajah A, Zulfiqar-Ali Q, Marques P, Rong M, Andrade DM. A systematic review of adults with Dravet syndrome. Seizure 2021; 87:39-45. [PMID: 33677403 DOI: 10.1016/j.seizure.2021.02.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 12/30/2022] Open
Abstract
Dravet Syndrome (DS) is a rare and severe infantile-onset epileptic encephalopathy. DS research focuses mainly on children. We did a systematic review, completed on January 18th, 2021, examining the number of clinical DS studies. We show that there are 208 studies on children exclusively, 28 studies on adults exclusively, and 116 studies involving adults and children combined. This 7:1 ratio of children to adult studies exclusively shows the dearth of research that addresses long-term natural history of DS into adulthood. Through this systematic review, we examine the most up-to-date information in DS adults as it pertains to seizures, electroencephalogram, imaging, treatment, motor abnormalities, cognitive and social behavior outcomes, cardiac abnormalities, sleep disturbances, diagnosis in adults, and mortality. Overall, the frequency of seizures increases in the first decade of life and then myoclonic, atypical absences and focal seizures with impaired awareness tend to decrease in frequency or even disappear in adulthood. Adults tend to have a notable reduction in status epilepticus, especially after 30 years of age. Parkinsonian features were seen in patients as young as 19 years old and are more severe in older patients, suggesting a progression of the parkinsonian symptoms. In adulthood, patients continue to present with behavior problems, associated with a lower health-related quality of life. The leading reported cause of death in DS adults is Sudden Unexpected Death in Epilepsy (SUDEP). Further studies in older adults are needed to understand the long-term outcomes of patients with DS.
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Affiliation(s)
- Arunan Selvarajah
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Canada; Adult Epilepsy Genetics Program, Division of Neurology, Krembil Research Institute, Toronto Western Hospital, Toronto, Canada
| | - Quratulain Zulfiqar-Ali
- Adult Epilepsy Genetics Program, Division of Neurology, Krembil Research Institute, Toronto Western Hospital, Toronto, Canada
| | - Paula Marques
- Adult Epilepsy Genetics Program, Division of Neurology, Krembil Research Institute, Toronto Western Hospital, Toronto, Canada; Division of Neurology, Department of Medicine, University of Toronto, ON, Canada
| | - Marlene Rong
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Canada; Adult Epilepsy Genetics Program, Division of Neurology, Krembil Research Institute, Toronto Western Hospital, Toronto, Canada
| | - Danielle M Andrade
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Canada; Adult Epilepsy Genetics Program, Division of Neurology, Krembil Research Institute, Toronto Western Hospital, Toronto, Canada; Division of Neurology, Department of Medicine, University of Toronto, ON, Canada; Krembil Neurosciences Institute, University Health Network, Toronto, ON, Canada.
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