Changes in the lymphocyte subsets during high dose immunoglobulin therapy for intractable childhood epilepsy

Intravenous immunoglobulins for epilepsy

BACKGROUND

Epilepsy is a common neurological condition, with an estimated incidence of 50 per 100,000 persons. People with epilepsy may present with various types of immunological abnormalities, such as low serum immunoglobulin A (IgA) levels, lack of the immunoglobulin G (IgG) subclass and identification of certain types of antibodies. Intravenous immunoglobulin (IVIg) treatment may represent a valuable approach and its efficacy has important implications for epilepsy management. This is an update of a Cochrane review first published in 2011 and last updated in 2017.

OBJECTIVES

To examine the effects of IVIg on the frequency and duration of seizures, quality of life and adverse effects when used as monotherapy or as add-on treatment for people with epilepsy.

SEARCH METHODS

For the latest update, we searched the Cochrane Register of Studies (CRS Web) (20 December 2018), MEDLINE (Ovid, 1946 to 20 December 2018), Web of Science (1898 to 20 December 2018), ISRCTN registry (20 December 2018), WHO International Clinical Trials Registry Platform (ICTRP, 20 December 2018), the US National Institutes of Health ClinicalTrials.gov (20 December 2018), and reference lists of articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials of IVIg as monotherapy or add-on treatment in people with epilepsy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the trials for inclusion and extracted data. We contacted study authors for additional information. Outcomes included percentage of people rendered seizure-free, 50% or greater reduction in seizure frequency, adverse effects, treatment withdrawal and quality of life.

MAIN RESULTS

We included one study (61 participants). The included study was a randomised, double-blind, placebo-controlled, multicentre trial which compared the treatment efficacy of IVIg as an add-on with a placebo add-on in patients with drug-resistant epilepsy. Seizure freedom was not reported in the study. There was no significant difference between IVIg and placebo in 50% or greater reduction in seizure frequency (RR 1.89, 95% CI 0.85 to 4.21; one study, 58 participants; low-certainty evidence). The study reported a statistically significant effect for global assessment in favour of IVIg (RR 3.29, 95% CI 1.13 to 9.57; one study, 60 participants; low-certainty evidence). No adverse effects were demonstrated. We found no randomised controlled trials that investigated the effects of IVIg monotherapy for epilepsy. Overall, the included study was rated at low to unclear risk of bias. Using GRADE methodology, the certainty of the evidence was rated as low.

AUTHORS' CONCLUSIONS

We cannot draw any reliable conclusions regarding the efficacy of IVIg as a treatment for epilepsy. Further randomised controlled trials are needed.

Intravenous immunoglobulins for epilepsy

BACKGROUND

Epilepsy is a common neurological condition, with an estimated incidence of 50 per 100,000 persons. People with epilepsy may present with various types of immunological abnormalities, such as low serum immunoglobulin A (IgA) levels, lack of the immunoglobulin G (IgG) subclass and identification of certain types of antibodies. Intravenous immunoglobulin (IVIg) treatment may represent a valuable approach and its efficacy has important implications for epilepsy management. This is an updated version of the original Cochrane review published in Issue 1, 2011.

OBJECTIVES

To examine the effects of IVIg on the frequency and duration of seizures, quality of life and adverse effects when used as monotherapy or as add-on treatment for people with epilepsy.

SEARCH METHODS

For the latest update, we searched the Cochrane Epilepsy Group Specialized Register (2 February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online (2 February 2017), MEDLINE (Ovid, 1946 to 2 February 2017), Web of Science (1898 to 2 February 2017), ISRCTN registry (2 February 2017), WHO International Clinical Trials Registry Platform (ICTRP, 2 February 2017), the US National Institutes of Health ClinicalTrials.gov (2 February 2017), and reference lists of articles.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials of IVIg as monotherapy or add-on treatment in people with epilepsy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the trials for inclusion and extracted data. We contacted study authors for additional information. Outcomes included percentage of people rendered seizure-free, 50% or greater reduction in seizure frequency, adverse effects, treatment withdrawal and quality of life.

MAIN RESULTS

We included one study (61 participants). The included study was a randomized, double-blind, placebo-controlled, multi-centre trial which compared the treatment efficacy of IVIg as an add-on with a placebo add-on in patients with refractory epilepsy. There was no significant difference between IVIg and placebo in 50% or greater reduction in seizure frequency. The study reported a statistically significant effect for global assessment in favour of IVIg. No adverse effects were demonstrated. We found no randomized controlled trials that investigated the effects of IVIg monotherapy for epilepsy. Overall, the included study was rated as low/unclear risk of bias. Using GRADE methodology, the quality of the evidence was rated as low.

AUTHORS' CONCLUSIONS

We cannot draw any reliable conclusions regarding the efficacy of IVIg as a treatment for epilepsy. Further randomized controlled trials are needed.

Intravenous immunoglobulins for epilepsy

BACKGROUND

Epilepsy is a common neurological condition, with an estimated incidence of 50 per 100,000 persons. People with epilepsy may present with various types of immunological abnormalities, such as low serum IgA level, lack of IgG subclass and identification of certain types of antibodies. Intravenous immunoglobulin (IVIg) treatment may represent a valuable approach and its efficacy has important implications for epilepsy management.

OBJECTIVES

To examine the effects of IVIg on the frequency and duration of seizures, quality of life and adverse effects, when used as monotherapy or as add-on treatment for people with epilepsy.

SEARCH STRATEGY

We searched the Cochrane Epilepsy Group Specialized Register (14 June 2010), the Cochrane Central Register of Controlled Trials (Issue 2 of 4, The Cochrane Library, 2010), MEDLINE (1950 to June 2010), Web of Science (14 June 2010), Current Controlled Trials (11 June 2010), the National Research Register (NRR) archive (11 June 2010), the US National Institutes of Health (Clinicaltrials.gov) (11 June 2010) and reference lists of articles.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials of IVIg as monotherapy or add-on treatment in people with epilepsy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the trials for inclusion and extracted data. We contacted study authors for additional information. Outcomes included percentage of people rendered seizure-free, 50% or greater reduction in seizure frequency, adverse effects, treatment withdrawal and quality of life.

MAIN RESULTS

We included one study (61 patients). We found no randomized controlled trials that investigated the effects of IVIg monotherapy for epilepsy. The included study was a randomized, double-blind, placebo-controlled, multi-center trial which compared the treatment efficacy of IVIg as an add-on with a placebo add-on in patients with refractory epilepsy. There was no significant difference between IVIg and placebo in 50% or greater reduction in seizure frequency. The study reported a statistically significant effect for global assessment in favor of IVIg. No adverse effects were demonstrated.

AUTHORS' CONCLUSIONS

No reliable conclusions can be drawn regarding the efficacy of IVIg as a treatment for epilepsy. Further randomized controlled trials are needed.

Improvement of intractable childhood epilepsy following acute viral infection

In this study, we report 11 patients with intractable childhood epilepsy that improved following acute viral infection. The patients were 8 boys and 3 girls. Six of the 11 children were diagnosed as West syndrome (5 of the symptomatic type and 1 of the cryptogenic type). The remaining 5 children were myoclonic seizures. The patients became seizure free within 6 days following acute viral infections without an exchange or addition of antiepileptic drugs (AEDs). The types of acute viral infections were Exanthema subitum (Roseola infantum) in 5 patients, Rotavirus gastroenteritis in 2 patients, Measles infection in 2 patients, Herpetic stomatitis in 1 patient and Common cold in the remaining patient. Salaam seizures and/or tonic spasms disappeared within 6 days after the onset of viral infections, and hypsarrhythmia evolved to localized spikes on electroencephalography (EEG) in the patients with West syndrome. Epileptic seizures disappeared rapidly and EEG gradually normalized or improved in patients with myoclonic seizures. Four patients became seizure free for 5 years to 20 years. In 6 patients, seizures relapsed within 14 days to 1 month after the disappearance of seizures. One child remained seizure free for 12 months after viral infection. Common factors in 4 children who were continuously seizure free include (1) normal or almost normal findings of brain CT/MRI, (2) normal development prior to the onset of epileptic seizures, and (3) a short time interval between the onset of seizures and the acute viral infection. We propose several hypotheses including an immunological effect for the improvement of intractable childhood epilepsy following acute viral infection. Further study may provide important information concerning the mechanism of seizure control and the applicable to treatment for intractable childhood epilepsy.