1
|
Pina-Garza JE, Chez M, Cloyd J, Hirsch LJ, Kälviäinen R, Klein P, Lagae L, Sankar R, Specchio N, Strzelczyk A, Toledo M, Trinka E. Outpatient management of prolonged seizures and seizure clusters to prevent progression to a higher-level emergency: Consensus recommendations of an expert working group. Epileptic Disord 2024. [PMID: 38813941 DOI: 10.1002/epd2.20243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 04/25/2024] [Accepted: 05/03/2024] [Indexed: 05/31/2024]
Abstract
OBJECTIVE The management of prolonged seizures (PS) and seizure clusters (SC) is impeded by the lack of international, evidence-based guidance. We aimed to develop expert recommendations regarding consensus definitions of PS, SC, and treatment goals to prevent progression to higher-level emergencies such as status epilepticus (SE). METHODS An expert working group, comprising 12 epileptologists, neurologists, and pharmacologists from Europe and North America, used a modified Delphi consensus methodology to develop and anonymously vote on statements. Consensus was defined as ≥75% voting "Agree"/"Strongly agree." RESULTS All group members strongly agreed that termination of an ongoing seizure in as short a time as possible is the primary goal of rapid and early seizure termination (REST) and that an ideal medication for REST would start to act within 2 min of administration to terminate ongoing seizure activity. Consensus was reached on the terminology defining PS (with proposed thresholds of 5 min for prolonged focal seizures and 2 min for prolonged absence seizures and the convulsive phase of bilateral tonic-clonic seizures) and SC (an abnormal increase in seizure frequency compared with the individual patient's usual seizure pattern). All group members strongly agreed or agreed that patients who have experienced a PS should be offered a REST medication, and all patients who have experienced a SC should be offered an acute cluster treatment (ACT). Further, when prescribing a REST medication or ACT, a seizure action plan should be agreed upon in consultation with the patient and caregiver. SIGNIFICANCE The expert working group had a high level of agreement on the recommendations for defining and managing PS and SC. These recommendations will complement the existing guidance for the management of acute seizures, with the possibility of treating them earlier to potentially avoid progression to more severe seizures, including SE.
Collapse
Affiliation(s)
| | - Michael Chez
- Sutter Neuroscience Institute, Sacramento, California, USA
| | - James Cloyd
- College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University, New Haven, Connecticut, USA
| | - Reetta Kälviäinen
- University of Eastern Finland and Epilepsy Center Kuopio University Hospital, Member of the European Reference Network EpiCARE, Kuopio, Finland
| | - Pavel Klein
- Mid-Atlantic Epilepsy and Sleep Center, Bethesda, Maryland, USA
| | - Lieven Lagae
- Department Development and Regeneration, Section Paediatric Neurology, Full Member of the European Reference Network EpiCARE, University Hospitals Leuven, Leuven, Belgium
| | - Raman Sankar
- David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Nicola Specchio
- Neurology, Epilepsy and Movement Disorders Unit, Full Member of the European Reference Network EpiCARE, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University and University Hospital Frankfurt, Frankfurt, Germany
| | - Manuel Toledo
- Epilepsy Unit, Neurology Department, Vall d' Hebron University Hospital, Barcelona, Spain
| | - Eugen Trinka
- Department of Neurology, Neurocritical Care and Neurorehabilitation, Christian Doppler Medical Centre, Centre for Cognitive Neuroscience, Member of the European Reference Network EpiCARE, Paracelsus Medical University, Salzburg, Austria
- Neuroscience Institute, Christian Doppler Medical Centre, Centre for Cognitive Neuroscience Salzburg Paracelsus Medical University, Salzburg, Austria
- Karl Landsteiner Institute of Neurorehabilitation and Space Neurology, Salzburg, Austria
- Department of Public Health, Health Services Research, and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| |
Collapse
|
2
|
Penovich PE, Rao VR, Long L, Carrazana E, Rabinowicz AL. Benzodiazepines for the Treatment of Seizure Clusters. CNS Drugs 2024; 38:125-140. [PMID: 38358613 PMCID: PMC10881644 DOI: 10.1007/s40263-023-01060-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2023] [Indexed: 02/16/2024]
Abstract
Patients with epilepsy may experience seizure clusters, which are described by the US Food and Drug Administration (FDA) as intermittent, stereotypic episodes of frequent seizure activity that are distinct from a patient's usual seizure pattern. Untreated seizure clusters may increase the risk for status epilepticus, as well as decrease quality of life and increase burden on patients and care partners. Benzodiazepine therapies are the mainstay for acute treatment of seizure clusters and are often administered by nonmedical care partners outside a healthcare facility. Three rescue therapies are currently FDA-approved for this indication, with diazepam rectal gel being the first in 1997, for patients aged ≥ 2 years. Limitations of rectal administration (e.g., positioning and disrobing the patient, which may affect ease of use and social acceptability; interpatient variation in bioavailability) led to the investigation of the potential for nasal administration as an alternative. Midazolam nasal spray (MDS) was approved by the FDA in 2019 for patients aged ≥ 12 years and diazepam nasal spray (DNS) in 2020 for patients aged ≥ 6 years; these two intranasal therapies have differences in their formulations [e.g., organic solvents (MDS) vs. Intravail and vitamin E for absorption and solubility (DNS)], effectiveness (e.g., proportion of seizure clusters requiring only one dose), and safety profiles. In clinical studies, the proportion of seizure clusters for which only one dose of medication was used varied between the three approved rescue therapies with the highest single-dose rate for any time period for DNS; however, although studies for all three preparations enrolled patients with highly intractable epilepsy, inclusion and exclusion criteria varied, so the three cannot be directly compared. Treatments that have been used off-label for seizure clusters in the USA include midazolam for injection as an intranasal spray (indicated for sedation/anxiolysis/amnesia and anesthesia) and tablet forms of clonazepam (indicated for treatment for seizure disorders) and lorazepam (indicated for anxiety). In the European Union, buccal and intranasal midazolam are used for treating the indication of prolonged, acute convulsive seizures and rectal diazepam solution for the indication of epileptic and febrile convulsions; duration of effectiveness for these medications for the treatment of seizure clusters has not been established. This paper examines the literature context for understanding seizure clusters and their treatment and provides effectiveness, safety, and administration details for the three FDA-approved rescue therapies. Additionally, other medications that are used for rescue therapy in the USA and globally are discussed. Finally, the potential benefits of seizure action plans and candidates for their use are addressed. This paper is intended to provide details about the unique characteristics of rescue therapies for seizure clusters to help clarify appropriate treatment for individual patients.
Collapse
Affiliation(s)
| | - Vikram R Rao
- University of California, San Francisco, CA, USA
| | - Lucretia Long
- Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Enrique Carrazana
- Neurelis, Inc., San Diego, CA, USA
- John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| | | |
Collapse
|
3
|
Gidal B, Welty T, Cokley J, Farrell M, Shafer P, Rabinowicz AL, Carrazana E. Opportunities for Community Pharmacists to Counsel Patients With Epilepsy and Seizure Clusters to Overcome Barriers and Foster Appropriate Treatment. J Pharm Pract 2024; 37:190-197. [PMID: 36193947 PMCID: PMC10804691 DOI: 10.1177/08971900221126570] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Some patients with epilepsy experience seizure clusters, which may be defined as 2 or more seizures occurring within 24 hours. Left untreated, seizure clusters increase the risk for physical injury and may progress to status epilepticus, irreversible neurologic injury, and death. Rescue therapy is based on benzodiazepine treatment. Prompt, appropriate use should be specified in patients' individualized seizure action plans. Most seizure clusters occur outside the hospital setting. The ideal rescue therapy allows for easy and quick administration by a nonmedical person, which may minimize the need for intervention by emergency medical personnel or transportation to the hospital. In the 2 decades before the approval of 2 intranasal benzodiazepines in 2019 and 2020, rectal diazepam was the only route of administration approved by the US Food and Drug Administration specifically for seizure clusters. Each of the approved intranasal formulations has a unique profile. Both offer a convenient and socially acceptable route of administration. Recognition of seizure clusters and timing of proper administration are key to successful use of rescue therapy. Pharmacists' counseling plays an important role in reinforcing when and how to appropriately administer rescue therapies and the importance of consistently using rescue treatment when indicated to promote effective management. This review includes resources for pharmacists, patients, and caregivers; reviews currently available treatments; and discusses seizure action plans that support effective treatment of seizure clusters.
Collapse
Affiliation(s)
- Barry Gidal
- University of Wisconsin School of Pharmacy, Madison, WI, USA
| | | | - Jon Cokley
- Texas Children’s Hospital, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
| | | | | | | | - Enrique Carrazana
- Neurelis, Inc., San Diego, CA, USA
- John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| |
Collapse
|
4
|
Balafas EG, Papakyriakopoulou PI, Kostomitsopoulos NG, Valsami GN. Intranasal Administration of a Polymeric Biodegradable Film to C57BL/6 Mice. JOURNAL OF THE AMERICAN ASSOCIATION FOR LABORATORY ANIMAL SCIENCE : JAALAS 2023; 62:179-184. [PMID: 36898691 PMCID: PMC10078934 DOI: 10.30802/aalas-jaalas-22-000091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/28/2022] [Accepted: 12/09/2022] [Indexed: 03/12/2023]
Abstract
Nasal drug delivery in rodents is a challenging procedure, especially for brain targeting, as the position of the material in the nasal cavity determines the success of the administration method. The objective of this study was to assess a novel intranasal administration technique for nose-to-brain delivery of biodegradable nasal films. The method was performed in C57BL/6 (n = 10; age, 8 wk) under inhaled sevoflurane. Twenty-four gauge catheters were used for the procedure. Hydroxypropyl methyl-cellulosebased film was formed in the lumen of the catheter and then delivered into the mouse nostril by pushing it out of the lumen using a trimmed and polished needle. Methylene blue was incorporated in the film-forming gel to indicate the delivery area in which the films were deposited. After administration, all mice recovered from anesthesia without incident. None of the mice showed any signs of injury, discomfort, or nose bleeding, thus allowing us to characterize the administration method as noninvasive. Furthermore, postmortem evaluation revealed olfactory-centered placement of the polymeric films, confirming the accuracy and repeatability of the method. In conclusion, this study documented the use of, a novel, noninvasive, intranasal administration technique for nose-to-brain drug delivery in biodegradable films for use in mice.
Collapse
Affiliation(s)
- Evangelos G Balafas
- Laboratory Animal Facility, Centre of Clinical and Experimental Surgery and Translational Research, Biomedical Research Foundation, Academy of Athens, Athens, Greece
| | - Paraskevi I Papakyriakopoulou
- Laboratory of Biopharmaceutics-Pharmacokinetics, Faculty of Pharmacy, National and Kapodistrian University of Athens, Panepistimiopolis Zografou, Athens, Greece;,
| | - Nikolaos G Kostomitsopoulos
- Laboratory Animal Facility, Centre of Clinical and Experimental Surgery and Translational Research, Biomedical Research Foundation, Academy of Athens, Athens, Greece
| | - Georgia N Valsami
- Laboratory of Biopharmaceutics-Pharmacokinetics, Faculty of Pharmacy, National and Kapodistrian University of Athens, Panepistimiopolis Zografou, Athens, Greece
| |
Collapse
|
5
|
Sha L, Yong X, Shao Z, Duan Y, Hong Q, Zhang J, Zhang Y, Chen L. Targeting adverse effects of antiseizure medication on offspring: current evidence and new strategies for safety. Expert Rev Neurother 2023; 23:141-156. [PMID: 36731825 DOI: 10.1080/14737175.2023.2176751] [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] [Indexed: 02/04/2023]
Abstract
INTRODUCTION For women with epilepsy of reproductive age, antiseizure medications (ASMs) are associated with an increased risk of offspring malformations. There are safety concerns for most anti-seizure medications in the perinatal period, and there is a clear need to identify safe medications. ASMs must transport through biological barriers to exert toxic effects on the fetus, and transporters play essential roles in trans-barrier drug transport. Therefore, it is vital to understand the distribution and properties of ASM-related transporters in biological barriers. AREAS COVERED This study reviews the structure, transporter distribution, and properties of the blood-brain, placental, and blood-milk barrier, and summarizes the existing evidence for the trans-barrier transport mechanism of ASMs and standard experimental models of biological barriers. EXPERT OPINION Ideal ASMs in the perinatal period should have the following characteristics: 1) Increased transport through the blood-brain barrier, and 2) Reduced transport of the placental and blood-milk barriers. Thus, only low-dose or almost no antiseizure medication could enter the fetus's body, which could decrease medication-induced fetal abnormalities. Based on the stimulated structure and molecular docking, we propose a development strategy for new ASMs targeting transporters of biological barriers to improve the perinatal treatment of female patients with epilepsy.
Collapse
Affiliation(s)
- Leihao Sha
- Department of Neurology, Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan
| | - Xihao Yong
- Division of Nephrology and Kidney Research Institute, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Zhenhua Shao
- Division of Nephrology and Kidney Research Institute, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yifei Duan
- Department of Neurology, Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan
| | - Qiulei Hong
- Department of Neurology, Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan
| | - Jifa Zhang
- Department of Neurology, Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan
| | - Yunwu Zhang
- The current form, Fujian Provincial Key Laboratory of Neurodegenerative Disease and Aging Research, Institute of Neuroscience, School of Medicine, Xiamen University, Xiamen, 361102, China
| | - Lei Chen
- Department of Neurology, Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan
| |
Collapse
|
6
|
Zhang M, Kou L, Qin Y, Chen J, Bai D, Zhao L, Lin H, Jiang G. A bibliometric analysis of the recent advances in diazepam from 2012 to 2021. Front Pharmacol 2022; 13:1042594. [DOI: 10.3389/fphar.2022.1042594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 10/24/2022] [Indexed: 11/11/2022] Open
Abstract
Background: Diazepam is a classic benzodiazepine drug that has been widely used for disorders such as anxiety, sleep disorders, and epilepsy, over the past 59 years. The study of diazepam has always been an important research topic. However, there are few bibliometric analyses or systematic studies in this field. This study undertook bibliometric and visual analysis to ascertain the current status of diazepam research, and to identify research hotspots and trends in the past 10 years, to better understand future developments in basic and clinical research.Methods: Articles and reviews of diazepam were retrieved from the Web of Science core collection. Using CiteSpace, VOSviewer, and Scimago Graphica software, countries, institutions, authors, journals, references, and keywords in the field were visually analyzed.Results: A total of 3,870 publications were included. Diazepam-related literature had high volumes of publications and citations. The majority of publications were from the USA and China. The highest number of publications and co-citations, among the authors, was by James M Cook. Epilepsia and the Latin American Journal of Pharmacy were the journals with the most publications on diazepam and Epilepsia was the most frequently cited journal. Through a comprehensive analysis of keywords and references, we found that current research on diazepam has focused on its mechanism of action, application in disease, pharmacokinetics, risk, assessment, and management of use, status epilepticus, gamma-aminobutyric acid receptors (GABAR), intranasal formulation, gephyrin, and that ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) is the current research hotspot.Conclusion: Research on diazepam is flourishing. We identified research hotspots and trends in diazepam research using bibliometric and visual analytic methods. The clinical applications, mechanisms of action, pharmacokinetics, and assessment and management of the use of diazepam are the focus of current research and the development trend of future research.
Collapse
|
7
|
Kotloski RJ, Gidal BE. Rescue Treatments for Seizure Clusters. Neurol Clin 2022; 40:927-937. [DOI: 10.1016/j.ncl.2022.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
|
8
|
Gidal B, Detyniecki K. Rescue therapies for seizure clusters: Pharmacology and target of treatments. Epilepsia 2022; 63 Suppl 1:S34-S44. [PMID: 35999174 PMCID: PMC9543841 DOI: 10.1111/epi.17341] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/08/2022] [Accepted: 06/08/2022] [Indexed: 12/03/2022]
Abstract
The primary goal of treatment for seizure clusters is cessation of the cluster to avoid progression to more severe conditions, such as prolonged seizures and status epilepticus. Rescue therapies are key components of treatment plans for patients with seizure clusters. Three rescue therapies are approved in the United States for the treatment of seizure clusters: diazepam rectal gel, midazolam nasal spray, and diazepam nasal spray. This review characterizes the pharmacological function of rescue therapies for seizure clusters, as well as describing γ‐aminobutyric acid A (GABAA) receptor functions. GABAA receptors are heteropentamers, consisting primarily of α1‐6, β1‐3, γ2, and δ subunits in the central nervous system. These subunits can traffic to and from the membrane to regulate membrane potential. Benzodiazepines, such as diazepam and midazolam, are positive allosteric modulators of GABAA receptors, the activation of which leads to an increase in intracellular chloride, hyperpolarization of the cell membrane, and a reduction in excitation. GABAA receptor subunit mutations, dysregulation of trafficking, and degradation are associated with epilepsy. Although benzodiazepines are effective GABAA receptor modulators, individual formulations have unique profiles in practice. Diazepam rectal gel is an effective rescue therapy for seizure clusters; however, adults and adolescents may have social reservations regarding its administration. Intranasal delivery of midazolam or diazepam is a promising alternative to rectal administration because these formulations offer easy, socially acceptable administration and exhibit a rapid onset. Off‐label benzodiazepines, such as orally disintegrating lorazepam and intranasal use of an intravenous formulation of midazolam via nasal atomizer, are less well characterized regarding bioavailability and tolerability compared with approved agents.
Collapse
Affiliation(s)
- Barry Gidal
- School of Pharmacy, University of Wisconsin-Madison, Madison, Wisconsin, United States
| | - Kamil Detyniecki
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, United States
| |
Collapse
|
9
|
Menegatou IM, Papakyriakopoulou P, Rekkas DM, Dallas P, Valsami G. Design of a Personalized Nasal Device (Matrix-Piston Nasal Device, MPD) for Drug Delivery: a 3D-Printing Application. AAPS PharmSciTech 2022; 23:205. [PMID: 35896930 PMCID: PMC9331025 DOI: 10.1208/s12249-022-02351-4] [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: 04/02/2022] [Accepted: 06/28/2022] [Indexed: 12/02/2022] Open
Abstract
The purpose of the current study is the development and the in vitro evaluation of a novel device for the nasal delivery of biodegradable polymeric films. The Matrix-Piston nasal Device (MPD) was designed and then printed employing Fused Deposition Modeling. Particularly, the CAD model of MPD was produced considering the human anatomical features of the nasal cavity and aiming to deliver the formulation on the olfactory region. The device consists of two independent parts constructed by different materials. For the 3D-printing process, different materials were tested to decide the most applicable for each part. More precisely, Thermoplastic Polyurethene (TPU) polymer was selected to print the matrix, while Acrylonitrile Butadiene Styrene (ABS) for the piston. Furthermore, two nasal casts were printed to be used for the assessment of the device. Namely, an hydroxypropyl-methyl cellulose-based drug-free film, containing polyethylene glycol 400 as plasticizer and methyl-β-cyclodextrin as permeation enhancer, was formed on the MPD to be tested for its ability to be detached from the device and positioned on the artificial olfactory region of the nasal cast. The deposition of the film on the targeted area of the semi-realistic nasal cast took place successfully.
Collapse
Affiliation(s)
- Ioanna-Maria Menegatou
- Department of Pharmacy, School of Health Sciences, National and Kapodistrian University of Athens, Panepistimiopolis, 15784, Zografou, Greece
| | - Paraskevi Papakyriakopoulou
- Department of Pharmacy, School of Health Sciences, National and Kapodistrian University of Athens, Panepistimiopolis, 15784, Zografou, Greece
| | - Dimitrios M Rekkas
- Department of Pharmacy, School of Health Sciences, National and Kapodistrian University of Athens, Panepistimiopolis, 15784, Zografou, Greece
| | - Paraskevas Dallas
- Department of Pharmacy, School of Health Sciences, National and Kapodistrian University of Athens, Panepistimiopolis, 15784, Zografou, Greece
| | - Georgia Valsami
- Department of Pharmacy, School of Health Sciences, National and Kapodistrian University of Athens, Panepistimiopolis, 15784, Zografou, Greece.
| |
Collapse
|
10
|
Rabinowicz AL, Faught E, Cook DF, Carrazana E. Implications of Seizure-Cluster Treatment on Healthcare Utilization: Use of Approved Rescue Medications. Neuropsychiatr Dis Treat 2022; 18:2431-2441. [PMID: 36325434 PMCID: PMC9619205 DOI: 10.2147/ndt.s376104] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/29/2022] [Indexed: 11/07/2022] Open
Abstract
PURPOSE People with epilepsy may experience seizure clusters despite a stable regimen of antiseizure medications. Such clusters have the potential to last ≥24 hours, typically occur in the community setting, and may progress to medical emergencies, such as status epilepticus, if untreated. Thus, long-acting rescue therapy for seizure clusters is needed that can be administered by nonmedical individuals outside a hospital. Benzodiazepines are the foundation of rescue therapy for seizure clusters. The approved outpatient treatments (ie, diazepam, midazolam) have differing profiles that may affect multiple aspects of health-care utilization. The current labeling of these medications allows for a second dose if needed to control the cluster. Although no head-to-head studies directly comparing rescue treatments have been conducted, differences between studies with generally similar designs may provide context for the potential importance of second doses of rescue therapy on health-care utilization. METHODS For this analysis, large, long-term, open-label studies of approved seizure-cluster treatments designed for use by nonmedical caregivers were reviewed, and the percentage of seizure clusters for which a second dose was used or that were not controlled at 6, 12, and 24 hours was examined. Available data on hospitalizations were also collected. RESULTS The 3 identified studies meeting the inclusion criteria were for use of diazepam rectal gel, intranasal midazolam, and diazepam nasal spray. Across these studies, the use of a second dose ranged from <40% at 6 hours to <13% at 24 hours. Hospitalizations and serious treatment-emergent adverse events were reported variably across these studies. CONCLUSION These results demonstrate the importance of second doses of rescue therapy for seizure clusters for optimizing health-care utilization. Need for second doses should be included as one component. In turn, when second doses are needed, they have the potential to curtail emergency department use and hospitalization and to prevent further seizure clusters.
Collapse
Affiliation(s)
| | - Edward Faught
- Emory Epilepsy Program, Emory University School of Medicine, Atlanta, GA, USA
| | - David F Cook
- Clinical Development & Medical Affairs, Neurelis, Inc., San Diego, CA, USA
| | - Enrique Carrazana
- Clinical Development & Medical Affairs, Neurelis, Inc., San Diego, CA, USA.,John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| |
Collapse
|
11
|
Wheless JW, Miller I, Hogan RE, Dlugos D, Biton V, Cascino GD, Sperling MR, Liow K, Vazquez B, Segal EB, Tarquinio D, Mauney W, Desai J, Rabinowicz AL, Carrazana E. Final results from a Phase 3, long-term, open-label, repeat-dose safety study of diazepam nasal spray for seizure clusters in patients with epilepsy. Epilepsia 2021; 62:2485-2495. [PMID: 34418086 PMCID: PMC9290500 DOI: 10.1111/epi.17041] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 07/12/2021] [Accepted: 08/02/2021] [Indexed: 11/29/2022]
Abstract
Objective A Phase 3 open‐label safety study (NCT02721069) evaluated long‐term safety of diazepam nasal spray (Valtoco) in patients with epilepsy and frequent seizure clusters. Methods Patients were 6–65 years old with diagnosed epilepsy and seizure clusters despite stable antiseizure medications. The treatment period was 12 months, with study visits at Day 30 and every 60 days thereafter, after which patients could elect to continue. Doses were based on age and weight. Seizure and treatment information was recorded in diaries. Treatment‐emergent adverse events (TEAEs), nasal irritation, and olfactory changes were recorded. Results Of 163 patients in the safety population, 117 (71.8%) completed the study. Duration of exposure was ≥12 months for 81.6% of patients. There was one death (sudden unexpected death in epilepsy) and one withdrawal owing to a TEAE (major depression), both considered unlikely to be related to treatment. Diazepam nasal spray was administered 4390 times for 3853 seizure clusters, with 485 clusters treated with a second dose within 24 h; 53.4% of patients had monthly average usage of one to two doses, 41.7% two to five doses, and 4.9% more than five doses. No serious TEAEs were considered to be treatment related. TEAEs possibly or probably related to treatment (n = 30) were most commonly nasal discomfort (6.1%); headache (2.5%); and dysgeusia, epistaxis, and somnolence (1.8% each). Only 13 patients (7.9%) showed nasal irritation, and there were no relevant olfactory changes. The safety profile of diazepam nasal spray was generally similar across subgroups based on age, monthly usage, concomitant benzodiazepine therapy, or seasonal allergy/rhinitis. Significance In this large open‐label safety study, the safety profile of diazepam nasal spray was consistent with the established profile of rectal diazepam, and the high retention rate supports effectiveness in this population. A second dose was used in only 12.6% of seizure clusters.
Collapse
Affiliation(s)
- James W Wheless
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Ian Miller
- Formerly Nicklaus Children's Hospital, Miami, Florida, USA
| | - R Edward Hogan
- Washington University in St. Louis, St. Louis, Missouri, USA
| | - Dennis Dlugos
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Victor Biton
- Arkansas Epilepsy Program, Little Rock, Arkansas, USA
| | | | | | - Kore Liow
- Hawaii Pacific Neuroscience, Honolulu, Hawaii, USA
| | - Blanca Vazquez
- New York University, Comprehensive Epilepsy Center, New York, New York, USA
| | - Eric B Segal
- Hackensack University Medical Center and Northeast Regional Epilepsy Group, Hackensack, New Jersey, USA
| | | | - Weldon Mauney
- Northwest Florida Clinical Research Group, Gulf Breeze, Florida, USA
| | - Jay Desai
- Children's Hospital of Los Angeles, Los Angeles, California, USA
| | | | | | | |
Collapse
|