New insights into the clinical management of partial epilepsies

Preliminary evidence for gender-specific effects of topiramate as a potential aid to smoking cessation

AIMS

Study aims were threefold: (i) to determine the feasibility, potential efficacy and safety of topiramate as an aid to smoking cessation; (ii) to examine potential predictors of abstinence including gender; and (iii) to explore topiramate's effects on tobacco withdrawal and post-cessation weight gain.

DESIGN

Randomized, double-blind, placebo-controlled, 11-week clinical trial with a 6-week dosage titration period and 5 weeks of maintenance treatment.

SETTING

Single-site, out-patient, randomized clinical trial.

PARTICIPANTS

Thirty-eight adult male and 49 female chronic smokers who smoked an average of > 10 cigarettes per day and who were motivated to try to quit smoking.

INTERVENTION

Random assignment to receive either topiramate (n = 43) up to 200 mg daily in divided doses or placebo (n = 44) orally combined with brief counseling over an 11-week period.

MEASUREMENTS

Carbon monoxide (CO)-confirmed 4-week prolonged abstinence rate during weeks 8-11. Changes in tobacco withdrawal, body weight and safety parameters were also assessed.

FINDINGS

Overall, no significant increase in the prolonged abstinence rate was detected, but logistic regression analysis indicated significant gender-specific differences. Men treated with topiramate were nearly 16 times more likely to quit smoking than women on topiramate [37.5% versus 3.7%; odds ratio (OR) = 15.6; P = 0.016] and were roughly four times more likely to quit smoking than placebo-treated men (37.5% versus 13.6%; OR = 3.8; P = 0.098). Topiramate-treated men reported significantly lower tobacco withdrawal scores than both women taking topiramate and men on placebo. On average, male cessators on placebo gained 3.30 kg, whereas topiramate led to a 0.72 kg weight loss (P = 0.03). Study discontinuation rates due to adverse events (AEs) were significantly higher in the topiramate group (topiramate 23% versus placebo 2%). The most commonly reported AEs in the topiramate arm were paraesthesia, fatigue, difficulty with concentration/attention and nervousness.

CONCLUSIONS

Topiramate produced gender-specific effects on smoking cessation. Male smokers had markedly greater quit rates than female smokers and men were roughly four times more likely to quit smoking when treated with topiramate as compared to placebo. Topiramate was fairly well tolerated, although higher discontinuation rates were seen. Topiramate's triple effects aiding smoking abstinence, attenuating nicotine withdrawal and preventing post-cessation weight gain might make it a promising agent for treating tobacco addiction, at least in men.

Anticonvulsants for the treatment of behavioral and psychological symptoms of dementia: a literature review

OBJECTIVE

To review and summarize the currently available data on the use of anticonvulsant mood stabilizers (carbamazepine, valproic acid, gabapentin, lamotrigine, topiramate) in the treatment of behavioral and psychological symptoms of dementia (BPSD); to determine whether these medications can be recommended for routine clinical use.

METHODS

Literature search in five databases (PubMed, MEDLINE, EMBASE, PsychINFO and COCHRANE collaboration) and analysis of the randomized controlled double-blinded clinical trials found therein.

RESULTS

A total of seven RCTs were identified (two for carbamazepine and five for valproate). One study showed statistically significant improvement of BPSD in the medication group in comparison to the placebo group; five studies showed no significant differences; one study showed statistically significant worsening of the symptoms in the medication group vs. placebo. The majority of the studies reported significantly more frequent adverse effects in the medication group.

CONCLUSION

Although clearly beneficial in some patients, anticonvulsant mood stabilizers cannot be recommended for routine use in the treatment of BPSD at the present time.

Greater functional recovery after temporal lobe epilepsy surgery in children

The purpose of our study is to evaluate whether children recover better than adults from memory deficits as a consequence of temporal lobe surgery. We compared 3 and 12 month outcomes obtained in children and adults with medically refractory epilepsy. Each candidate underwent temporal lobe resection for seizure control and children were matched with regard to pathology, onset of epilepsy, side of surgery and type of surgery with adults (N = 30 for each group, mean age at surgery 13 versus 30 years). Three months after surgery, both left-resected groups displayed a significant decline in verbal learning capacity. During the following 9 months, only the children recovered and were able to reach their preoperative level 1 year after surgery. The left-resected adults remained, for the most part, on their low level and one year after surgery, they were still significantly worse than at the time of their preoperative examination. The right-resected adults experienced a deterioration in visual memory 1 year after surgery relative to the results of the short-term follow-up; the children improved. The children also had a better outcome with regard to attentional functions and, as a trend, a better seizure outcome (Engel Outcome I--1 year after surgery: 63% adults, 80% paediatric patients). Our neuropsychological data provide evidence of greater plasticity and compensational capacity in childhood. The results can be taken as a strong argument for early surgical intervention.

Tiagabine as add-on therapy may be more effective with valproic acid--open label, multicentre study of patients with focal epilepsy

The aim of the current study was to review the efficacy of tiagabine (TGB) as add-on therapy in patients with drug-resistant focal epilepsy under normal daily clinical practice, and try to identify those who had improvement. This was an open multicentre study conducted in Poland. A group of 330 patients were analysed. Patients received TGB up to 30-50 mg/day with adjustment within the therapeutic range and titration period. For statistical evaluation chi-square test and logistic analysis were used. At the 16-week follow-up visit, 71.4% patients were reported as responders, i.e. had a 50% or greater decrease in seizure frequency compared with baseline (P<0.001). One-third of patients were seizure-free at 16-week evaluation (P<0.001). The beneficial effect of TGB on seizure reduction was most marked in patients with partial seizures (P<0.001). Patients who used valproic acid (mean dose 1307 mg/day) had 61-85% higher chances for disappearance of seizures or reduction of their number by 50% or more. Patients who used carbamazepine (mean dose 800 mg/day) at a dose 1000 mg or higher mg/day had twice lower chance for reduction of seizures by 50% or more (OR=0.45; 95 CI 0.25-0.82). There was no statistical impact of sex, age and aetiology on probability of therapeutic effect.