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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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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. [PMID: 38962968 DOI: 10.1002/epi4.12998] [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: 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 Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lieven Lagae
- Member of the European Reference Network EpiCARE, Department of Pediatric Neurology, University of Leuven, Leuven, Belgium
| | - Ingrid E Scheffer
- Austin Hospital and Royal Children''s Hospital, Florey and Murdoch Children's Research Institutes, University of Melbourne, Melbourne, Victoria, Australia
| | - J Helen Cross
- Developmental Neurosciences Research & Teaching Department, UCL NIHR BRC Great Ormond Street Institute of Child Health, London, UK
- Department of Neurology, Great Ormond Street Hospital, London, UK
| | - Nicola Specchio
- Neurology, Epilepsy and Movement Disorders Unit, Bambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network EpiCARE, Rome, Italy
| | - Adam Strzelczyk
- Goethe-University Frankfurt, Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, University Hospital Frankfurt, Frankfurt am Main, Germany
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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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Wong JC, Escayg A. Carvedilol increases seizure resistance in a mouse model of SCN8A-derived epilepsy. Front Pharmacol 2024; 15:1397225. [PMID: 38895634 PMCID: PMC11184058 DOI: 10.3389/fphar.2024.1397225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 05/14/2024] [Indexed: 06/21/2024] Open
Abstract
Patients with mutations that alter the function of the sodium channel SCN8A present with a range of clinical features, including mild to severe seizures, developmental delay, intellectual disability, autism, feeding dysfunction, motor impairment, and hypotonia. In an effort to identify compounds that could be potentially beneficial in SCN8A-associated epilepsy, Atkin et al. conducted an in vitro screen which resulted in the identification of 90 compounds that effectively reduced sodium influx into the cells expressing the human SCN8A R1872Q mutation. The top compounds that emerged from this screen included amitriptyline, carvedilol, and nilvadipine. In the current study, we evaluated the ability of these three compounds to increase resistance to 6 Hz or pentylenetetrazole (PTZ)-induced seizures in wild-type CF1 mice and in a mouse line expressing the human SCN8A R1620L mutation. We also evaluated the effects of fenfluramine administration, which was recently associated with a 60%-90% decrease in seizure frequency in three patients with SCN8A-associated epilepsy. While amitriptyline, carvedilol, and fenfluramine provided robust protection against induced seizures in CF1 mice, only carvedilol was able to significantly increase resistance to 6 Hz- and PTZ-induced seizures in RL/+ mutants. These results provide support for further evaluation of carvedilol as a potential treatment for patients with SCN8A mutations.
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Affiliation(s)
- Jennifer C. Wong
- Department of Human Genetics, Emory University, Atlanta, GA, United States
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Besag FMC, Vasey MJ, Chin RFM. Evaluating fenfluramine hydrochloride as an oral solution for the treatment of seizures associated with Lennox-Gastaut syndrome. Expert Rev Neurother 2024; 24:235-249. [PMID: 38315124 DOI: 10.1080/14737175.2024.2313548] [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: 12/01/2023] [Accepted: 01/29/2024] [Indexed: 02/07/2024]
Abstract
INTRODUCTION Lennox-Gastaut syndrome (LGS) is a severe childhood-onset developmental and epileptic encephalopathy characterized by treatment-refractory seizures, including tonic/atonic 'drop' seizures, and intellectual impairment and slow spike-wave discharges on the electroencephalogram. Fenfluramine, previously prescribed as a weight-loss drug but then withdrawn, has recently been approved in the US, EU, and UK for the adjunct treatment of seizures associated with LGS. AREAS COVERED The authors review the efficacy and safety findings from clinical trials of fenfluramine in LGS. The authors then discuss the evidence for adverse effects that may be of particular concern to fenfluramine, namely cardiac abnormalities, and weight loss, in the context of the use of fenfluramine for the treatment of the refractory seizures in LGS. EXPERT OPINION Fenfluramine has demonstrated efficacy in reducing the frequency of seizures in LGS, notably drop seizures, in short-term and long-term clinical trials. Valvular heart disease and pulmonary hypertension have not been reported at the low doses (≤26 mg/day) used in these studies, however, data are limited. Due to its novel mechanism of action, fenfluramine may be of benefit in LGS which has not responded adequately to other antiseizure medications. However, none of these medications, including fenfluramine, achieves the ultimate goal of seizure freedom in most cases.
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Affiliation(s)
- Frank M C Besag
- Child and Adolescent Mental Health Services (CAMHS), East London NHS Foundation Trust, Bedford, UK
- School of Pharmacy, University College London, London, UK
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Michael J Vasey
- Child and Adolescent Mental Health Services (CAMHS), East London NHS Foundation Trust, Bedford, UK
| | - Richard F M Chin
- Muir Maxwell Epilepsy Centre, The University of Edinburgh, Edinburgh, UK
- Department of Paediatric Neurosciences, Royal Hospital for Children and Young People, Edinburgh, UK
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Valls Carbó A, Beltrán Á, Sánchez-Miranda Román I, Cabal B, Gómez-Porro P, Aledo-Serrano Á, López Sobrino G, Ayuga F, Gómez Eguilaz M, Gil-Nagel A. What have we learned from the real-world efficacy of FFA in DS and LGS? A post-marketing study in clinical practice. Epilepsy Behav 2024; 151:109620. [PMID: 38194770 DOI: 10.1016/j.yebeh.2024.109620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 12/29/2023] [Accepted: 01/02/2024] [Indexed: 01/11/2024]
Abstract
OBJECTIVE To evaluate the effectiveness and tolerability of fenfluramine (FFA) in routine clinical practice treating real-world populations with Dravet syndrome (DS) and Lennox-Gastaut syndrome (LGS). METHODS This was a retrospective analysis of patients with DS or LGS who initiated FFA treatment from 2018 to 2022 at a single center. Patient demographics, medical history, seizure characteristics, and treatment outcomes were collected from electronic medical records. Duration of FFA treatment, dosage regimens, seizure frequency, seizure severity, improvements in cognitive, social, and motor outcomes, and adverse events were extracted and analyzed. Effectiveness was assessed using ≥50 % sustained reduction in monthly seizure frequency vs baseline for ≥2 consecutive months at 12 months; seizure freedom was a secondary measure. RESULTS Seizure frequency data was available for 56 of 68 patients included in the study. At 12 months, 50 patients (89.3 %) remained on FFA treatment; 58 % of these patients achieved a ≥50 % sustained response and 10 % experienced seizure freedom. Cognitive, motor, and social improvement were noted in 70.7 %, 36.2 %, and 27.6 % of patients, respectively. The total number of concomitant antiseizure medications was reduced by ≥1 in 29.4 % of patients. No differences were found between DS and LGS patients in these outcomes; age at start of FFA and age at the 12-month timepoint did not have an effect. At least one AE was experienced by 59.7% of patients; in 86.5% of the cases, AEs were plausibly related to treatment. While 70.3% of AEs were self-resolving and 81.8% of the remaining patients experienced mild AEs, 1 patient experienced a serious AE unrelated to FFA which resulted in the patient's death. There were no cases of pulmonary arterial hypertension or ventricular heart disease. SIGNIFICANCE The effectiveness and tolerability of FFA treatment in patients with DS or LGS in this retrospective analysis of real-world data were consistent with those seen in randomized clinical trials.
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Affiliation(s)
| | - Álvaro Beltrán
- Neurology department, Hospital Ruber Internacional, Madrid, Spain.
| | | | | | | | - Ángel Aledo-Serrano
- Neurology department, Hospital Ruber Internacional, Madrid, Spain; Vithas Neuroscience Institute, Madrid Spain
| | - Gloria López Sobrino
- Neurology department, Hospital Ruber Internacional, Madrid, Spain; Hospital Universitario La Paz, Madrid, Spain.
| | - Fernando Ayuga
- Hospital Quirónsalud Toledo, Toledo, Spain; Hospital Universitario de Toledo, Toledo, Spain
| | | | - Antonio Gil-Nagel
- Fundación Iniciativa para las Neurociencias (FINCE), Madrid, Spain; Neurology department, Hospital Ruber Internacional, Madrid, Spain.
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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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Sills GJ. Pharmacological diversity amongst approved and emerging antiseizure medications for the treatment of developmental and epileptic encephalopathies. Ther Adv Neurol Disord 2023; 16:17562864231191000. [PMID: 37655228 PMCID: PMC10467199 DOI: 10.1177/17562864231191000] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 07/13/2023] [Indexed: 09/02/2023] Open
Abstract
Developmental and epileptic encephalopathies (DEEs) are rare neurodevelopmental disorders characterised by early-onset and often intractable seizures and developmental delay/regression, and include Dravet syndrome and Lennox-Gastaut syndrome (LGS). Rufinamide, fenfluramine, stiripentol, cannabidiol and ganaxolone are antiseizure medications (ASMs) with diverse mechanisms of action that have been approved for treating specific DEEs. Rufinamide is thought to suppress neuronal hyperexcitability by preventing the functional recycling of voltage-gated sodium channels from the inactivated to resting state. It is licensed for adjunctive treatment of seizures associated with LGS. Fenfluramine increases extracellular serotonin levels and may reduce seizures via activation of specific serotonin receptors and positive modulation of the sigma-1 receptor. Fenfluramine is licensed for adjunctive treatment of seizures associated with Dravet syndrome and LGS. Stiripentol is a positive allosteric modulator of type-A gamma-aminobutyric acid (GABAA) receptors. As a broad-spectrum inhibitor of cytochrome P450 enzymes, its antiseizure effects may additionally arise through pharmacokinetic interactions with co-administered ASMs. Stiripentol is licensed for treating seizures associated with Dravet syndrome in patients taking clobazam and/or valproate. The mechanism(s) of action of cannabidiol remains largely unclear although multiple targets have been proposed, including transient receptor potential vanilloid 1, G protein-coupled receptor 55 and equilibrative nucleoside transporter 1. Cannabidiol is licensed as adjunctive treatment in conjunction with clobazam for seizures associated with Dravet syndrome and LGS, and as adjunctive treatment of seizures associated with tuberous sclerosis complex. Like stiripentol, ganaxolone is a positive allosteric modulator at GABAA receptors. It has recently been licensed in the USA for the treatment of seizures associated with cyclin-dependent kinase-like 5 deficiency disorder. Greater understanding of the causes of DEEs has driven research into the potential use of other novel and repurposed agents. Putative ASMs currently in clinical development for use in DEEs include soticlestat, carisbamate, verapamil, radiprodil, clemizole and lorcaserin.
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Affiliation(s)
- Graeme J. Sills
- School of Life Sciences, University of Glasgow, Room 341, Sir James Black Building, Glasgow G12 8QQ, UK
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Gerasimova S, Lebedeva A, Gromov N, Malkov A, Fedulina А, Levanova T, Pisarchik A. Memristive Neural Networks for Predicting Seizure Activity. Sovrem Tekhnologii Med 2023; 15:30-38. [PMID: 38434190 PMCID: PMC10902902 DOI: 10.17691/stm2023.15.4.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Indexed: 03/05/2024] Open
Abstract
The aim of the study is to assess the possibilities of predicting epileptiform activity using the neuronal activity data recorded from the hippocampus and medial entorhinal cortex of mice with chronic epileptiform activity. To reach this goal, a deep artificial neural network (ANN) has been developed and its implementation based on memristive devices has been demonstrated. Materials and Methods The biological part of the investigation. Young healthy outbred CD1 mice were used in our study. They were divided into two groups: control (n=6) and the group with induced chronic epileptiform activity (n=6). Local field potentials (LFP) were recorded from the hippocampus and medial entorhinal cortex of the mice of both groups to register neuronal activity. The LFP recordings were used for deep ANN training. Epileptiform activity in mice was modeled by intraperitoneal injection of pilocarpine (280 mg/kg). LFP were recorded in the awake mice a month after the induction of epileptiform activity.Mathematical part of the investigation. A deep long short-term memory (LSTM) ANN capable of predicting biological signals of neuronal activity in mice has been developed. The ANN implementation is based on memristive devices, which are described by the equations of the redox processes running in the memristive thin metal-oxide-metal films, e.g., Au/ZrO2(Y)/TiN/Ti and Au/SiO2(Y)/TiN/Ti. In order to train the developed ANN to predict epileptiform activity, a supervised learning algorithm was used, which allowed us to adjust the network parameters and train LSTM on the described recordings of neuronal activity. Results After training on the LFP recordings from the hippocampus and medial entorhinal cortex of the mice with chronic epileptiform activity, the proposed deep ANN has demonstrated high values of evaluation metric (root-mean-square error, RMSE) and successfully predicted epileptiform activity shortly before its occurrence (40 ms). The results of the numerical experiments have shown that the RMSE value of 0.019 was reached, which indicates the efficacy of proposed approach. The accuracy of epileptiform activity prediction 40 ms before its occurrence is a significant result and shows the potential of the developed neural network architecture. Conclusion The proposed deep ANN can be used to predict pathological neuronal activity including epileptic seizure (focal) activity in mice before its actual occurrence. Besides, it can be applied for building a long-term prognosis of the disease course based on the LFP data. Thus, the proposed ANN based on memristive devices represents a novel approach to the prediction and analysis of pathological neuronal activity possessing a potential for improving the diagnosis and prognostication of epileptic seizures and other diseases associated with neuronal activity.
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Affiliation(s)
- S.A. Gerasimova
- Researcher, Research Laboratory of Perspective Methods of Multidimensional Data Analysis, Institute of Information Technologies, Mathematics, and Mechanics; National Research Lobachevsky State University of Nizhny Novgorod, 23 Prospekt Gagarina, Nizhny Novgorod, 603022, Russia
| | - A.V. Lebedeva
- Associate Professor, Department of Neurotechnologies, Institute of Biology and Biomedicine; National Research Lobachevsky State University of Nizhny Novgorod, 23 Prospekt Gagarina, Nizhny Novgorod, 603022, Russia
| | - N.V. Gromov
- Laboratory Research Assistant, Research Laboratory of Perspective Methods of Multidimensional Data Analysis, Institute of Information Technologies, Mathematics, and Mechanics; National Research Lobachevsky State University of Nizhny Novgorod, 23 Prospekt Gagarina, Nizhny Novgorod, 603022, Russia
| | - A.E. Malkov
- Senior Researcher, Laboratory of Systemic Organization of Neurons; Institute of Theoretical and Experimental Biophysics of Russian Academy of Sciences, 3 Institutskaya St., Puschino, Moscow Region, 142290, Russia
| | - А.А. Fedulina
- Junior Researcher, Laboratory of Brain Development Genetics, Research Institute of Neurosciences; National Research Lobachevsky State University of Nizhny Novgorod, 23 Prospekt Gagarina, Nizhny Novgorod, 603022, Russia
| | - T.A. Levanova
- Associate Professor, Department of System Dynamics and Control Theory, Institute of Information Technologies, Mathematics, and Mechanics; National Research Lobachevsky State University of Nizhny Novgorod, 23 Prospekt Gagarina, Nizhny Novgorod, 603022, Russia
| | - A.N. Pisarchik
- Head of the Laboratory of Computational Biology, Center for Biomedical Technology; Universidad Politécnica de Madrid, Madrid, 28223, Spain
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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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Sankar R, Chez M, Pina-Garza JE, Dixon-Salazar T, Flamini JR, Hyslop A, McGoldrick P, Millichap JJ, Resnick T, Rho JM, Wolf S. Proposed anti-seizure medication combinations with rufinamide in the treatment of Lennox-Gastaut syndrome: Narrative review and expert opinion. Seizure 2023; 110:42-57. [PMID: 37321047 DOI: 10.1016/j.seizure.2023.05.018] [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: 03/30/2023] [Revised: 05/03/2023] [Accepted: 05/24/2023] [Indexed: 06/17/2023] Open
Abstract
Lennox-Gastaut syndrome (LGS) is a severe, chronic, complex form of early childhood-onset epilepsy characterized by multiple seizure types, generalized slow (≤2.5 Hz) spike-and-wave activity and other electroencephalography abnormalities, and cognitive impairment. A key treatment goal is early seizure control, and several anti-seizure medications (ASMs) are available. Due to the low success rate in achieving seizure control with monotherapy and an absence of efficacy data supporting any particular combination of ASMs for treating LGS, a rational approach to selection of appropriate polytherapy should be applied to maximize benefit to patients. Such "rational polytherapy" involves consideration of factors including safety (including boxed warnings), potential drug-drug interactions, and complementary mechanisms of action. Based on the authors' clinical experience, rufinamide offers a well-considered first adjunctive therapy for LGS, particularly in combination with clobazam and other newer agents for LGS, and may be particularly useful for reducing the frequency of tonic-atonic seizures associated with LGS.
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Affiliation(s)
- Raman Sankar
- Departments of Neurology and Pediatrics, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, USA; UCLA Mattel Children's Hospital, Los Angeles, CA, USA.
| | - Michael Chez
- Sutter Health, Roseville, CA, USA; California Northstate University School of Medicine, Elk Grove, CA, USA
| | | | | | | | - Ann Hyslop
- Stanford University School of Medicine, Palo Alto, CA, USA
| | - Patricia McGoldrick
- Boston Children's Health Physicians, Valhalla, NY, USA; Maria Fareri Children's Hospital, Valhalla, NY, USA; New York Medical College, Valhalla, NY, USA
| | - John J Millichap
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Jong M Rho
- Departments of Neurosciences, Pediatrics & Pharmacology, University of California San Diego and Rady Children's Hospital, San Diego, CA, USA
| | - Steven Wolf
- Boston Children's Health Physicians, Valhalla, NY, USA; Maria Fareri Children's Hospital, Valhalla, NY, USA; New York Medical College, Valhalla, NY, USA
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Besag FMC, Vasey MJ, Chin RFM. Current and emerging pharmacotherapy for the treatment of Lennox-Gastaut syndrome. Expert Opin Pharmacother 2023; 24:1249-1268. [PMID: 37212330 DOI: 10.1080/14656566.2023.2215924] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 05/16/2023] [Indexed: 05/23/2023]
Abstract
INTRODUCTION Lennox-Gastaut syndrome (LGS) is a severe childhood-onset epileptic encephalopathy, characterized by multiple seizure types, generalized slow spike-and-wave complexes in the EEG, and cognitive impairment. Seizures in LGS are typically resistant to treatment with antiseizure medications (ASMs). Tonic/atonic ('drop') seizures are of particular concern, due to their liability to cause physical injury. AREAS COVERED We summarize evidence for current and emerging ASMs for the treatment of seizures in LGS. The review focuses on findings from randomized, double-blind, placebo-controlled trials (RDBCTs). For ASMs for which no double-blind trials were identified, lower quality evidence was considered. Novel pharmacological agents currently undergoing investigation for the treatment of LGS are also briefly discussed. EXPERT OPINION Evidence from RDBCTs supports the use of cannabidiol, clobazam, felbamate, fenfluramine, lamotrigine, rufinamide, and topiramate as adjunct treatments for drop seizures. Percentage decreases in drop seizure frequency ranged from 68.3% with high-dose clobazam to 14.8% with topiramate. Valproate continues to be considered the first-line treatment, despite the absence of RDBCTs specifically in LGS. Most individuals with LGS will require treatment with multiple ASMs. Treatment decisions should be individualized and take into account adverse effects, comorbidities, general quality of life, and drug interactions, as well as individual efficacy.
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Affiliation(s)
- Frank M C Besag
- East London NHS Foundation Trust, Bedford, UK
- School of Pharmacy, University College London, London, UK
- Department of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | | | - Richard F M Chin
- Muir Maxwell Epilepsy Centre, The University of Edinburgh, Edinburgh, UK
- Department of Paediatric Neurosciences, Royal Hospital for Children and Young People, Edinburgh, UK
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Efficacy and Safety of Fenfluramine in Epilepsy: A Systematic Review and Meta-analysis. Neurol Ther 2023; 12:669-686. [PMID: 36853503 PMCID: PMC10043095 DOI: 10.1007/s40120-023-00452-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 02/07/2023] [Indexed: 03/01/2023] Open
Abstract
INTRODUCTION Fenfluramine (FFA) is an amphetamine derivative that promotes the release and blocks the neuronal reuptake of serotonin. Initially introduced as an appetite suppressant, FFA also showed antiseizure properties. This systematic review aimed to assess the efficacy and safety of FFA for the treatment of seizures in patients with epilepsy. METHODS We systematically searched (in week 3 of June 2022) MEDLINE, the Cochrane Central Register of Controlled Trials, and the US National Institutes of Health Clinical Trials Registry. Randomized, double- or single-blinded, placebo-controlled studies of FFA in patients with epilepsy and uncontrolled seizures were identified. Efficacy outcomes included the proportions of patients with ≥ 50% and 100% reductions in baseline seizure frequency during the treatment period. Tolerability outcomes included the proportions of patients who withdrew from treatment for any reason and suffered adverse events (AEs). The risk of bias in the included studies was assessed according to the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions. The risk ratio (RR) along with the 95% confidence interval (CI) were estimated for each outcome. RESULTS Three trials were identified and a total of 469 Dravet syndrome (DS) and Lennox-Gastaut syndrome (LGS) subjects were randomized. All three trials were judged to be at low risk of biases. In patients with DS, the RRs for ≥ 50% and 100% reductions in convulsive seizure frequency for the FFA group compared to placebo were 5.61 (95% CI 2.73-11.54) and 4.71 (95% CI 0.57-39.30), respectively. In patients with LGS, the corresponding RRs for ≥ 50% and 100% reductions in drop seizure frequency were 2.58 (95% CI 1.33-5.02) and 0.50 (95% CI 0.031-7.81), respectively. The drug was withdrawn for any reason in 10.1% and 5.8% of patients receiving FFA and placebo, respectively (RR 1.79, 95% CI 0.89-3.59). Treatment discontinuation due to AEs occurred in 5.4% and 1.2% of FFA- and placebo-treated patients, respectively (RR 3.63, 95% CI 0.93-14.16). Decreased appetite, diarrhoea, fatigue, and weight loss were AEs associated with FFA treatment. CONCLUSION Fenfluramine reduces the frequency of seizures in patients with DS and LGS. Decreased appetite, diarrhoea, fatigue, and weight loss are non-cardiovascular AEs associated with FFA.
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