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Mulheron S, Leahy TP, McStravick M, Doran R, Delanty N. A comparison of cenobamate with other newer antiseizure medications for adjunctive treatment of focal-onset seizures: A systematic review and network meta-analysis. Seizure 2024; 118:80-90. [PMID: 38643679 DOI: 10.1016/j.seizure.2024.04.004] [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: 02/16/2024] [Revised: 04/04/2024] [Accepted: 04/04/2024] [Indexed: 04/23/2024] Open
Abstract
PURPOSE To compare the efficacy, safety, and tolerability of cenobamate with other newer anti-seizure medications (ASMs) including brivaracetam, eslicarbazepine, lacosamide, perampanel, and zonisamide, approved for adjunctive treatment of drug-resistant focal-onset seizures (FOS) in adults with epilepsy. METHODS A systematic literature review (SLR) was conducted to obtain relevant efficacy, safety, and tolerability data for ASMs for the treatment of drug-resistant FOS. All studies were thoroughly assessed for potential sources of heterogeneity and analysed via Bayesian network meta-analyses (NMAs). Efficacy outcomes were ≥50 % responder rate and seizure freedom during the maintenance period, which were modelled simultaneously using a multinomial Bayesian NMA. Safety and tolerability outcomes were the proportion of patients who experienced at least one treatment-emergent adverse event (TEAE) and the proportion who experienced at least one TEAE leading to discontinuation. RESULTS The SLR identified 76 studies, of which 23 were included in the Bayesian NMAs. Cenobamate was associated with statistically significant higher rates for the ≥50 % responder rate and seizure freedom outcomes compared with all ASMs analysed. The point estimates indicated that cenobamate was associated with higher rates of experiencing at least one TEAE and at least one TEAE leading to discontinuation compared with brivaracetam, lacosamide, and zonisamide; however, no results were statistically significant. CONCLUSION Cenobamate was associated with increased efficacy compared with all ASMs analysed. There were no statistically significant differences in the safety and tolerability outcomes. The results presented corroborate the conclusions drawn from previous published NMAs, which also highlight the notable efficacy of cenobamate in comparison with other ASMs.
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Affiliation(s)
- Stuart Mulheron
- Angelini Pharma UK-I, Napier House, 24 High Holborn, London WC1V 6AZ, UK.
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Yamamoto Y, Shiratani Y, Nishida T, Usui N, Imai K, Kagawa Y, Takahashi Y. Effects of low-dose titration on the tolerability and safety of perampanel. Epilepsy Behav 2023; 143:109213. [PMID: 37126869 DOI: 10.1016/j.yebeh.2023.109213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/27/2023] [Accepted: 04/04/2023] [Indexed: 05/03/2023]
Abstract
PURPOSE To evaluate the effects of low-dose titration on the tolerability and safety of perampanel. METHODS We retrospectively reviewed the records of 1065 patients who started perampanel therapy and compared the incidence of adverse events after standard titration (Group A: starting dose, 2 mg/day; titration speed, 2 mg/2 weeks or longer) and low-dose titration (Group B: starting dose, < 1 mg/day; titration speed, < 1 mg/2 weeks or longer). RESULTS Adverse events were reported in 158 patients (14.8%) within the initial first 90 days of starting perampanel (mean concentration, 331 ng/mL). At 90 days, the cumulative incidence of adverse events was significantly higher in Group A than in Group B (24.5% vs. 16.3%, respectively; log-rank test p < 0.001). A Cox proportional hazards model also showed that low-dose titration decreased the incidence risk of adverse events (adjusted hazard ratio, 0.49; 95% confidence interval, 0.35-0.69). When the groups were stratified by use of enzyme-inducing antiseizure medications (inducers), Group A patients without inducers had a significantly higher cumulative incidence of adverse events than the other three subgroups (26.7%, p < 0.001). In patients taking 2 mg of perampanel, median concentrations in patients with or without inducers were 43 ng/mL and 204 ng/mL, respectively. CONCLUSION Perampanel is generally initiated at 2 mg, but serum perampanel concentrations show substantial interindividual variation. Our study suggests that care must be taken when setting the starting dose of perampanel. In particular, low-dose titration is recommended in patients not taking inducers.
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Affiliation(s)
- Yoshiaki Yamamoto
- Department of Clinical Research, NHO, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, 886 Urushiyama, Shizuoka 420-8688, Japan; Department of Clinical Pharmaceutics, Graduate School of Pharmaceutical Sciences, University of Shizuoka, 52-1 Yada, Shizuoka 422-8526, Japan.
| | - Yuka Shiratani
- Department of Clinical Research, NHO, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, 886 Urushiyama, Shizuoka 420-8688, Japan
| | - Takuji Nishida
- Department of Clinical Research, NHO, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, 886 Urushiyama, Shizuoka 420-8688, Japan
| | - Naotaka Usui
- Department of Clinical Research, NHO, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, 886 Urushiyama, Shizuoka 420-8688, Japan
| | - Katsumi Imai
- Department of Clinical Research, NHO, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, 886 Urushiyama, Shizuoka 420-8688, Japan
| | - Yoshiyuki Kagawa
- Department of Clinical Pharmaceutics, Graduate School of Pharmaceutical Sciences, University of Shizuoka, 52-1 Yada, Shizuoka 422-8526, Japan; Laboratory of Clinical Pharmacokinetics and Drug Safety, Shizuoka General Hospital, 4-27-1 Kita Ando, Shizuoka 420-8527, Japan
| | - Yukitoshi Takahashi
- Department of Clinical Research, NHO, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, 886 Urushiyama, Shizuoka 420-8688, Japan; Department of Clinical Pharmaceutics, Graduate School of Pharmaceutical Sciences, University of Shizuoka, 52-1 Yada, Shizuoka 422-8526, Japan
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Abstract
BACKGROUND Epilepsy is one of the most common neurological disorders. Approximately 30% of people with epilepsy are considered to be drug-resistant, and usually need treatment with a combination of other antiepileptic drugs. Perampanel is a newer antiepileptic drug that has been investigated as add-on therapy for drug-resistant focal epilepsy. OBJECTIVES To evaluate the benefits and harms of perampanel as add-on therapy for people with drug-resistant focal epilepsy. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 20 October 2022. SELECTION CRITERIA We included randomised controlled trials comparing add-on perampanel with placebo. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcome was 1. 50% or greater reduction in seizure frequency. Our secondary outcomes were 2. seizure freedom, 3. treatment withdrawal due to any reason, 4. treatment withdrawal due to adverse effects, and 5. ADVERSE EFFECTS We used an intention-to-treat population for all primary analyses. We presented the results as risk ratios (RR) with 95% confidence intervals (CIs), except for individual adverse effects, which we reported with 99% CIs to compensate for multiple testing. We used GRADE to assess certainty of evidence for each outcome. MAIN RESULTS We included seven trials involving 2524 participants, all aged over 12 years. The trials were double-blind, randomised, placebo-controlled trials with treatment duration of 12 to 19 weeks. We assessed four trials at overall low risk of bias, and three trials at overall unclear risk of bias, due to risk of detection, reporting, and other biases. Compared with placebo, participants receiving perampanel were more likely to achieve a 50% or greater reduction in seizure frequency (RR 1.67, 95% CI 1.43 to 1.95; 7 trials, 2524 participants; high-certainty evidence). Compared to placebo, perampanel increased seizure freedom (RR 2.50, 95% CI 1.38 to 4.54; 5 trials, 2323 participants; low-certainty evidence) and treatment withdrawal (RR 1.30, 95% CI 1.03 to 1.63; 7 trials, 2524 participants; low-certainty evidence). Participants treated with perampanel were more likely to withdraw from treatment due to adverse effects compared to those receiving placebo (RR 2.36, 95% CI 1.59 to 3.51; 7 trials, 2524 participants; low-certainty evidence). A higher proportion of participants receiving perampanel reported one or more adverse effects when compared to participants who received placebo (RR 1.17, 95% CI 1.10 to 1.24; 7 trials, 2524 participants; high-certainty evidence). Compared with placebo, participants receiving perampanel were more likely to experience ataxia (RR 14.32, 99% CI 1.09 to 188.31; 2 trials, 1098 participants; low-certainty evidence), dizziness (RR 2.87, 99% CI 1.45 to 5.70; 7 trials, 2524 participants; low-certainty evidence), and somnolence (RR 1.76, 99% CI 1.02 to 3.04; 7 trials, 2524 participants). Subgroup analysis indicated that a larger proportion of participants who received perampanel at a dose of 4 mg/day (RR 1.38, 95% CI 1.05 to 1.83; 2 trials, 710 participants), 8 mg/day (RR 1.83, 95% CI 1.51 to 2.22; 4 trials, 1227 participants), or 12 mg/day (RR 2.38, 95% CI 1.86 to 3.04; 3 trials, 869 participants) achieved a 50% or greater reduction in seizure frequency compared to placebo; however, treatment with perampanel 12 mg/day also increased treatment withdrawal (RR 1.77, 95% CI 1.31 to 2.40; 3 trials, 869 participants). AUTHORS' CONCLUSIONS Add-on perampanel is effective at reducing seizure frequency and may be effective at maintaining seizure freedom for people with drug-resistant focal epilepsy. Although perampanel was well-tolerated, there was a higher proportion of treatment withdrawals with perampanel compared with placebo. Subgroup analysis suggested that 8 mg/day and 12 mg/day are the most efficacious perampanel doses; however, the use of 12 mg/day would likely increase the number of treatment withdrawals. Future research should focus on investigating the efficacy and tolerability of perampanel with longer-term follow-up, as well as exploring an optimal dose.
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Affiliation(s)
- Rebecca Bresnahan
- Liverpool Reviews and Implementation Group, Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Ruaraidh A Hill
- Liverpool Reviews and Implementation Group, Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Jin Wang
- Department of Neurology, The First Affiliated Hospital, Guangxi Medical University, Nanning, China
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Hou L, Yang J, Zhang X, Li N, Li S, Zhang L, Zhao J, Wang Q. Efficacy and tolerability of perampanel in patients with seizures in real-world clinical practice: A systematic review and meta-analysis. Front Pharmacol 2023; 14:1139514. [PMID: 37056989 PMCID: PMC10086234 DOI: 10.3389/fphar.2023.1139514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 03/13/2023] [Indexed: 03/30/2023] Open
Abstract
Objectives: The aim of this study was to systematically review the efficacy and tolerability of perampanel (PER) when used as add-on treatment or monotherapy in patients with epilepsy aged 12 years and older in routine clinical practice.Methods: Electronic and clinical trials databases were searched for observational studies of PER published up to 1 March 2022. The outcomes of interest were responder rates, adverse effects (AEs), and withdrawal rates. Subgroup analyses were performed to explore the potential factors that might affect the efficacy and safety of PER usage.Results: A total of 56 studies, which included 10,688 patients, were enrolled. The results showed that after 3, 6, and 12 months of PER treatment, the pooled 50% responder rates in patients with epilepsy were 50.0% (95% CI: 0.41–0.60), 44.0% (95% CI: 0.38–0.50), and 39.0% (95% CI: 0.31–0.48), respectively, and the pooled seizure-free rates were 24.0% (95% CI: 0.17–0.32), 21.0% (95% CI: 0.17–0.25), and 20.0% (95% CI: 0.16–0.24), respectively. Subgroup analyses revealed that the efficacy of PER could be affected by the way in which PER is administrated. Patients in the groups where PER was used as the first add-on, primary monotherapy, or combined with non–enzyme-inducing AEDs (non-EIAEDs) displayed a high 50% responder rate and seizure-free rate when compared with those in the late add-on, conversion therapy, or combined with the EIAEDs groups, respectively. Furthermore, the incidences of AEs at 3, 6, and 12 months of PER treatment were 46% (95% CI: 0.38–0.55), 52.0% (95% CI: 0.43–0.60), and 46.0% (95% CI: 0.40–0.52), respectively. The withdrawal rates due to AEs were 8.0% (95% CI: 0.06–0.11), 16.0% (95% CI: 0.13–0.20), and 16% (95% CI: 0.11–0.21) at 3, 6, and 12 months of PER treatment, respectively. Subgroup analyses showed a higher withdrawal rate in the rapid (30%, 95% CI: 0.22–0.38) than in the slow (12%, 95% CI: 0.06–0.18) titration group.Conclusion: Altogether, PER was effective and could be fairly tolerated in both short-term and long-term usage in patients with epilepsy in routine clinical practice. Furthermore, PER appeared to be more effective when PER was used as the first add-on, monotherapy, or concomitant with non-EIAEDs.Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022384532.
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Affiliation(s)
- Liyan Hou
- Dalian Medical University Library, Dalian Medical University, Dalian, China
| | - Jingjing Yang
- Department of Neurology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xuan Zhang
- National-Local Joint Engineering Research Center for Drug-Research and Development R & D of Neurodegenerative Diseases, Dalian Medical University, Dalian, China
| | - Na Li
- National-Local Joint Engineering Research Center for Drug-Research and Development R & D of Neurodegenerative Diseases, Dalian Medical University, Dalian, China
| | - Sheng Li
- National-Local Joint Engineering Research Center for Drug-Research and Development R & D of Neurodegenerative Diseases, Dalian Medical University, Dalian, China
| | - Lei Zhang
- Dalian Medical University Library, Dalian Medical University, Dalian, China
- *Correspondence: Lei Zhang, ; Jie Zhao, ; Qingshan Wang,
| | - Jie Zhao
- National-Local Joint Engineering Research Center for Drug-Research and Development R & D of Neurodegenerative Diseases, Dalian Medical University, Dalian, China
- *Correspondence: Lei Zhang, ; Jie Zhao, ; Qingshan Wang,
| | - Qingshan Wang
- National-Local Joint Engineering Research Center for Drug-Research and Development R & D of Neurodegenerative Diseases, Dalian Medical University, Dalian, China
- School of Public Health, Dalian Medical University, Dalian, China
- *Correspondence: Lei Zhang, ; Jie Zhao, ; Qingshan Wang,
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Liu P, Zhu Z, Wu H. The safety of perampanel in different disorders and doses: A meta-analysis. Seizure 2023; 106:22-28. [PMID: 36724644 DOI: 10.1016/j.seizure.2023.01.013] [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: 09/22/2022] [Revised: 01/17/2023] [Accepted: 01/19/2023] [Indexed: 01/22/2023] Open
Abstract
PURPOSE To investigate the safety of perampanel in different disorders and doses. METHODS Embase, the Cochrane Library, Medline, and ClinicalTrials.gov were searched from inception to July 2022 for randomized controlled trials (RCTs). The meta-analysis was performed by using Review Manager 5.3 and R 4.2.1 software. RESULTS A total of 17 RCTs with 5711 subjects were included in the final analysis. The double-blind treatment phase was from 12 weeks to 48 weeks. Our results showed that 11 adverse events (aggression, ataxia, balance disorder, dizziness, fall, fatigue, irritability, rash, somnolence, vertigo, and weight increase) were statistically significantly associated with perampanel, and 4 of them (ataxia, dizziness, fatigue, and somnolence) showed a clear dose-response relationship. Psychiatric adverse events occurred most frequently among serious treatment-emergent adverse events (TEAEs). At 8 mg/day, seven adverse events (aggression, balance disorder, dizziness, fatigue, irritability, vertigo, and weight increase) occurred more frequently in patients with epilepsy than in patients with other disorders, whereas dose discontinuation rates due to adverse events were lower in patients with epilepsy than in patients with other disorders. CONCLUSION The safety profile of perampanel is dependent on diseases and dose. The risk of adverse events was statistically significantly higher, with doses exceeding 4 mg/day. Despite a higher risk of adverse events, patients with epilepsy had a lower perampanel discontinuation rate than patients with other disorders.
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Affiliation(s)
- Ping Liu
- Graduate School of Hebei Medical University, Shijiazhuang, Hebei Province, China; Department of Pharmacy, Hebei General Hospital; No. 348, West Heping Road, Shijiazhuang, Hebei Province 050051, China
| | - Zhongning Zhu
- Department of Pharmacology, Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Huizhen Wu
- Graduate School of Hebei Medical University, Shijiazhuang, Hebei Province, China; Department of Pharmacy, Hebei General Hospital; No. 348, West Heping Road, Shijiazhuang, Hebei Province 050051, China.
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Lavu A, Aboulatta L, Abou-Setta AM, Aloud B, Askin N, Rabbani R, Shouman W, Zarychanski R, Eltonsy S. Efficacy and safety of perampanel in epilepsy: A systematic review and meta-analysis of randomised controlled trials. Seizure 2022; 102:54-60. [DOI: 10.1016/j.seizure.2022.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/18/2022] [Accepted: 09/28/2022] [Indexed: 11/26/2022] Open
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Mahajan SS, Prakash A, Sarma P, Niraj N, Bhattacharyya A, Medhi B. Efficacy, tolerability and safety of perampanel in population with pharmacoresistant focal seizures: A Systematic review and meta-analysis. Epilepsy Res 2022; 182:106895. [DOI: 10.1016/j.eplepsyres.2022.106895] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/25/2022] [Accepted: 03/01/2022] [Indexed: 12/01/2022]
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Hotait M, Ismail HH, Saab GE, Salameh JS. An open label pilot study of the safety and tolerability of perampanel in amyotrophic lateral sclerosis. Muscle Nerve 2021; 64:504-508. [PMID: 34322897 DOI: 10.1002/mus.27385] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/21/2021] [Accepted: 07/24/2021] [Indexed: 11/07/2022]
Abstract
INTRODUCTION/AIMS Perampanel, a selective noncompetitive α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) antagonist, is capable of slowing the progression of the amyotrophic lateral sclerosis (ALS) phenotype and increasing the number of anterior horn cells in transgenic mice. Trials of perampanel in epilepsy showed a favorable tolerability profile. In this study we aimed to determine the tolerability and safety of perampanel in patients with ALS. METHODS Enrolled subjects were started on 2 mg/day of perampanel and the dose was increased by 2 mg/day every week to a maximum dose of 8 mg/day. Our primary outcome measure was tolerability, which was evaluated by monitoring adverse events. The secondary outcome measure was clinical progression, assessed using the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-R) and spirometry. RESULTS Six participants were enrolled. All had adverse events, mostly behavioral. Two completed the trial and the other four withdrew due to adverse events. All participants reported resolution of these events after discontinuation of the drug. The trial was halted due to the large number of adverse events. DISCUSSION The use of perampanel in this study of ALS was limited by its poor tolerability.
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Affiliation(s)
- Mostafa Hotait
- Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
| | - Helen H Ismail
- Department of Neurology, American University of Beirut medical Center, Beirut, Lebanon
| | - Georges E Saab
- Department of Neurology, American University of Beirut medical Center, Beirut, Lebanon
| | - Johnny S Salameh
- Department of Neurology, American University of Beirut medical Center, Beirut, Lebanon
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Jeon J, Oh J, Yu KS. A meta-analysis: efficacy and safety of anti-epileptic drugs prescribed in Korea as monotherapy and adjunctive treatment for patients with focal epilepsy. Transl Clin Pharmacol 2021; 29:6-20. [PMID: 33854997 PMCID: PMC8020359 DOI: 10.12793/tcp.2021.29.e1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/16/2020] [Accepted: 12/28/2020] [Indexed: 01/08/2023] Open
Abstract
Focal epilepsy is the most common type of epilepsy in Korea, and anti-epileptic drugs (AEDs) are the main treatment option for patients. This study aimed to compare the efficacy and safety of AEDs for focal epilepsy through a meta-analysis. The AEDs prescribed in Korea as monotherapy and adjunctive treatment for patients with focal epilepsy were included for analysis. Relevant articles were searched for randomized clinical trials of AEDs and treatment outcomes were analyzed on the basis of the 50% responder rate, seizure-free rate, treatment withdrawal rate, and emergence rates of adverse events (AEs). The odds ratios (ORs) and their 95% confidence intervals (CI) of study outcome were calculated using combined data from multiple studies. A total of 47 studies were included in the meta-analysis. The seizure-free rate, treatment withdrawal rate, and AE rate were not significantly different among the AEDs recommended for monotherapy. Among the AEDs recommended for adjunctive treatment, topiramate and oxcarbazepine yielded the highest OR in comparison with placebo for each efficacy parameter: the 50% responder rate for topiramate = 6.42 (3.76–11.6) and the seizure-free rate for oxcarbazepine = 32.7 (6.05–899). The third-generation AEDs (brivaracetam and perampanel) yielded relatively better safety outcomes than other AEDs. In general, the 50% responder rate and treatment withdrawal rate tended to increase as the dose of the AEDs increased. The results from the current meta-analysis of the efficacy and safety data of various AEDs may provide insight into optimal pharmacotherapy for the treatment of focal epilepsy.
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Affiliation(s)
- JuYeun Jeon
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul 03080, Korea
| | - Jaeseong Oh
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul 03080, Korea
| | - Kyung-Sang Yu
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul 03080, Korea
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Rektor I, Krauss GL, Inoue Y, Kaneko S, Williams B, Patten A, Malhotra M, Laurenza A, Wechsler RT. Assessment of the long-term efficacy and safety of adjunctive perampanel in tonic-clonic seizures: Analysis of four open-label extension studies. Epilepsia 2020; 61:1491-1502. [PMID: 32645213 PMCID: PMC7497073 DOI: 10.1111/epi.16573] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/18/2020] [Accepted: 05/18/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This post hoc analysis evaluated long-term efficacy and safety in patients with focal to bilateral tonic-clonic seizures (FBTCS) or generalized tonic-clonic seizures (GTCS) who entered open-label extension (OLEx) studies to receive long-term adjunctive perampanel. METHODS Patients aged 12 years and older who completed phase II or III randomized, double-blind, placebo-controlled studies could enter an OLEx study, each comprising a blinded conversion period followed by an open-label maintenance period (32-424 weeks; maximum perampanel dose = 12 mg/d). Exposure, seizure outcomes, and treatment-emergent adverse events (TEAEs) were analyzed. RESULTS Baseline characteristics were generally balanced between patients with FBTCS (n = 720) and GTCS (n = 138). Mean (standard deviation) cumulative duration of perampanel exposure was 102.3 (70.3) weeks (FBTCS) and 83.9 (38.4) weeks (GTCS). Retention rates were 50.0% for up to 4 years (FBTCS) and 49.2% for up to 2 years (GTCS). Across OLEx treatment durations, median reductions in seizure frequency per 28 days were 66.7% (FBTCS) and 80.6% (GTCS). Fifty percent and 75% responder and seizure-freedom rates were 59.5%, 45.3%, and 18.4%, respectively (FBTCS), and 72.5%, 51.5%, and 16.7%, respectively (GTCS). Efficacy was sustained for up to 4 years (FBTCS) and up to 3 years (GTCS), even when accounting for early dropouts. TEAE incidence was highest during Year 1 (FBTCS, 85.3%; GTCS, 86.2%); most common were dizziness and somnolence. During Year 1, serious TEAEs were reported in 81 (11.3%; FBTCS) and 10 (7.2%; GTCS) patients. TEAEs were consistent with the known safety profile of perampanel; no new safety signals were identified with long-term treatment. SIGNIFICANCE This post hoc analysis suggests long-term (up to 4 years) adjunctive perampanel (up to 12 mg/d) is efficacious and well tolerated in patients (aged 12 years and older) with FBTCS or GTCS.
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Affiliation(s)
- Ivan Rektor
- Brno Epilepsy Center and Central European Institute of Technology (CEITEC), Masaryk University, Brno, Czech Republic
| | - Gregory L Krauss
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yushi Inoue
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka, Japan
| | - Sunao Kaneko
- North Tohoku Epilepsy Center, Minato Hospital, Hachinohe, Japan
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Casillas‐Espinosa PM, Ali I, O'Brien TJ. Neurodegenerative pathways as targets for acquired epilepsy therapy development. Epilepsia Open 2020; 5:138-154. [PMID: 32524040 PMCID: PMC7278567 DOI: 10.1002/epi4.12386] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 02/13/2020] [Accepted: 02/24/2020] [Indexed: 12/16/2022] Open
Abstract
There is a growing body of clinical and experimental evidence that neurodegenerative diseases and epileptogenesis after an acquired brain insult may share common etiological mechanisms. Acquired epilepsy commonly develops as a comorbid condition in patients with neurodegenerative diseases such as Alzheimer's disease, although it is likely much under diagnosed in practice. Progressive neurodegeneration has also been described after traumatic brain injury, stroke, and other forms of brain insults. Moreover, recent evidence has shown that acquired epilepsy is often a progressive disorder that is associated with the development of drug resistance, cognitive decline, and worsening of other neuropsychiatric comorbidities. Therefore, new pharmacological therapies that target neurobiological pathways that underpin neurodegenerative diseases have potential to have both an anti-epileptogenic and disease-modifying effect on the seizures in patients with acquired epilepsy, and also mitigate the progressive neurocognitive and neuropsychiatric comorbidities. Here, we review the neurodegenerative pathways that are plausible targets for the development of novel therapies that could prevent the development or modify the progression of acquired epilepsy, and the supporting published experimental and clinical evidence.
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Affiliation(s)
- Pablo M. Casillas‐Espinosa
- Departments of Neuroscience and MedicineCentral Clinical SchoolMonash UniversityMelbourneVic.Australia
- Department of MedicineThe Royal Melbourne HospitalThe University of MelbourneMelbourneVic.Australia
| | - Idrish Ali
- Departments of Neuroscience and MedicineCentral Clinical SchoolMonash UniversityMelbourneVic.Australia
- Department of MedicineThe Royal Melbourne HospitalThe University of MelbourneMelbourneVic.Australia
| | - Terence J. O'Brien
- Departments of Neuroscience and MedicineCentral Clinical SchoolMonash UniversityMelbourneVic.Australia
- Department of MedicineThe Royal Melbourne HospitalThe University of MelbourneMelbourneVic.Australia
- Department of NeurologyThe Alfred HospitalMelbourneVic.Australia
- Department of NeurologyThe Royal Melbourne HospitalParkvilleVic.Australia
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Rocamora R, Álvarez I, Chavarría B, Principe A. Perampanel effect on sleep architecture in patients with epilepsy. Seizure 2020; 76:137-142. [PMID: 32086182 DOI: 10.1016/j.seizure.2020.01.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/27/2020] [Accepted: 01/31/2020] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Among patients with epilepsy, sleep disturbances can worsen seizure control. This prospective open-label study determined the effect of the antiepileptic drug perampanel on sleep architecture in patients with refractory epilepsy. METHODS Adult patients with refractory epilepsy received add-on perampanel, starting at 2 mg/day at bedtime, increased by 2 mg after 2 weeks and then monthly until the target dose of 4-8 mg/day was reached. The median dose of perampanel used was 6 mg (SD 1.2). Polysomnographic (PSG) recordings were scheduled 1 week before starting perampanel and the control PSG after 12 weeks under perampanel treatment and at least 4 weeks on stable perampanel dose; patients completed the Epworth Sleepiness Scale (ESS) and Pittsburgh Sleep Quality Index (PSQI) questionnaires. The main endpoints were change from baseline in the ESS and PSQI scores, and PSG variables. RESULTS Of 25 patients included (aged 18-65 years, 56 % female) only 17 completed the study. Perampanel caused a modest decrease from baseline in mean ESS score (n = 13 patients; p = 0.126) and PSQI score (n = 12 patients; p = 0.127). Treatment significantly improved sleep parameters (n = 17 patients) including total sleep time (p = 0.037), sleep latency (p = 0.022), sleep efficiency (p = 0.015), sleep maintenance index (p = 0.005), wake time after sleep onset (p = 0.015), and duration of N3 sleep stage (p = 0.026). Patients with altered sleep efficiency parameters at baseline showed a significant increase in sleep maintenance index (p = 0.015), and 77.8 % achieved sleep efficiency >85 % (p = 0.016 vs baseline). CONCLUSION Perampanel improved sleep architecture in patients with focal refractory epilepsy without worsening daytime sleepiness.
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Affiliation(s)
- Rodrigo Rocamora
- Epilepsy Monitoring Unit, Department of Neurology, Hospital del Mar Medical Research Institute, Carrer Aiguader, 88, 08003, Barcelona, Spain; Faculty of Health and Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain.
| | - Ion Álvarez
- Epilepsy Monitoring Unit, Department of Neurology, Hospital del Mar Medical Research Institute, Carrer Aiguader, 88, 08003, Barcelona, Spain.
| | - Beatriz Chavarría
- Epilepsy Monitoring Unit, Department of Neurology, Hospital del Mar Medical Research Institute, Carrer Aiguader, 88, 08003, Barcelona, Spain.
| | - Alessandro Principe
- Epilepsy Monitoring Unit, Department of Neurology, Hospital del Mar Medical Research Institute, Carrer Aiguader, 88, 08003, Barcelona, Spain; Faculty of Health and Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain.
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Kim JH, Kim DW, Lee SK, Seo DW, Lee JW, Park HJ, Lee SA. First add-on perampanel for focal-onset seizures: An open-label, prospective study. Acta Neurol Scand 2020; 141:132-140. [PMID: 31745975 PMCID: PMC6973118 DOI: 10.1111/ane.13197] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 11/14/2019] [Accepted: 11/16/2019] [Indexed: 11/29/2022]
Abstract
Objectives This study aimed to determine the efficacy and safety of perampanel added to monotherapy in patients with focal‐onset seizures, with or without secondarily generalized tonic‐clonic seizures. Materials & Methods In this multicentre, open‐label trial, enrolled patients were treated with perampanel monotherapy. During a 12‐week titration period, perampanel was incrementally increased by 2 mg/d over ≥2‐week intervals. Patients then entered a 24‐week maintenance period. The primary objective was to investigate the 50% responder rate in total seizure frequency, with 75% and 100% responder rates as secondary objectives. Treatment‐emergent adverse events (TEAEs) and adverse drug reactions were recorded. A post hoc analysis was performed to investigate the effect of titration speed and different concomitant AEDs on the efficacy and safety of perampanel. Results Of the 85 patients analysed, seizure reductions of 50%, 75% and 100% were observed in 80.0% (95% confidence interval [CI]: 69.9‐87.9), 71.8% (95% CI: 61.0‐81.0) and 47.1% (95% CI: 36.1‐58.2) during the maintenance period, respectively. The 50%, 75% and 100% response rates in patients with secondarily generalized tonic‐clonic seizures were 87.5% (95% CI: 61.7‐98.5), 87.5% (95% CI: 61.7‐98.5) and 75.0% (95% CI: 47.6‐92.7), respectively. The most common TEAEs were dizziness (50.0%), somnolence (9.8%) and headache (8.8%). The efficacy outcomes and safety profile of perampanel were more favourable with slow titration and relatively consistent when stratified by concomitant AEDs. Conclusions Perampanel was effective and well tolerated as a first add‐on to monotherapy in patients with focal‐onset seizures, with or without secondarily generalized seizures.
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Affiliation(s)
- Ji Hyun Kim
- Department of Neurology Korea University Guro Hospital Seoul Korea
| | - Dong Wook Kim
- Department of Neurology Konkuk University School of Medicine Seoul Korea
| | - Sang Kun Lee
- Department of Neurology Seoul National University Hospital Seoul Korea
| | - Dae Won Seo
- Department of Neurology Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | | | | | - Sang Ahm Lee
- Department of Neurology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
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Willems LM, Bauer S, Rosenow F, Strzelczyk A. Recent advances in the pharmacotherapy of epilepsy: brivaracetam and perampanel as broad-spectrum antiseizure drugs for the treatment of epilepsies and status epilepticus. Expert Opin Pharmacother 2019; 20:1755-1765. [DOI: 10.1080/14656566.2019.1637420] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Laurent Maximilian Willems
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Sebastian Bauer
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany
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Tyrlikova I, Brazdil M, Rektor I, Tyrlik M. Perampanel as monotherapy and adjunctive therapy for focal onset seizures, focal to bilateral tonic-clonic seizures and as adjunctive therapy of generalized onset tonic-clonic seizures. Expert Rev Neurother 2018; 19:5-16. [DOI: 10.1080/14737175.2019.1555474] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Ivana Tyrlikova
- Mid-Atlantic Epilepsy and Sleep Center, Bethesda, MD, USA
- Brno Epilepsy Center, 1st Department of Neurology, St. Anne’s Univ. Hospital and Medical Faculty of Masaryk University, Brno, Czech Republic
| | - Milan Brazdil
- Brno Epilepsy Center, 1st Department of Neurology, St. Anne’s Univ. Hospital and Medical Faculty of Masaryk University, Brno, Czech Republic
- Central European Institute of Technology, Masaryk University, Brno, Czech Republic
| | - Ivan Rektor
- Brno Epilepsy Center, 1st Department of Neurology, St. Anne’s Univ. Hospital and Medical Faculty of Masaryk University, Brno, Czech Republic
- Central European Institute of Technology, Masaryk University, Brno, Czech Republic
| | - Michal Tyrlik
- Mid-Atlantic Epilepsy and Sleep Center, Bethesda, MD, USA
- University of Maryland, College Park, USA
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Usui N, Akamatsu N, Nakasato N, Ohnishi A, Kaneko S, Hiramatsu H, Saeki K, Miyagishi H, Inoue Y. Long-term tolerability, safety and efficacy of adjunctive perampanel in the open-label, dose-ascending Study 231 and extension Study 233 in Japanese patients with epilepsy. Seizure 2018; 62:26-32. [DOI: 10.1016/j.seizure.2018.09.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 09/12/2018] [Accepted: 09/14/2018] [Indexed: 12/14/2022] Open
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Kwan P, Mintzer S, Laurenza A, Patten A, Cartwright K. Evaluation of perampanel as monotherapy for focal seizures: Experience from open-label extension studies. EPILEPSY & BEHAVIOR CASE REPORTS 2017; 9:1-5. [PMID: 29707476 PMCID: PMC5916525 DOI: 10.1016/j.ebcr.2017.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 11/10/2017] [Accepted: 11/22/2017] [Indexed: 11/19/2022]
Abstract
Perampanel, a selective, non-competitive α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor antagonist, is approved for adjunctive treatment of focal seizures, with or without secondarily generalized seizures, and for primary generalized tonic–clonic seizures in patients with epilepsy aged ≥ 12 years. Perampanel was recently approved for monotherapy use for focal seizures in the U.S.A. Anti-seizure drug monotherapy may be preferable to polytherapy, which is generally associated with increased toxicity, non-compliance, and cost. Here, we report cases where patients had converted to perampanel monotherapy during open-label extension (OLEx) portions of 9 Phase II and III studies. Of 2245 patients who enrolled in the OLEx studies, we identified 7 patients with drug-resistant focal seizures who discontinued all non-perampanel anti-seizure drugs and were maintained on perampanel monotherapy for ≥ 91 days until the end of data cut-off. Patients received perampanel monotherapy for up to 1099 days (157 weeks), most at a modal dose of 12 mg. Seizure data were available for 6 patients, of whom 5 had a ≥ 90% reduction in overall seizure frequency between baseline and their last 13-week period of monotherapy (3 were seizure-free). Perampanel monotherapy was generally well tolerated and the safety profile during perampanel monotherapy was consistent with clinical and post-marketing experience in the adjunctive setting. This analysis included a small proportion of patients with highly drug-resistant focal seizures who converted to monotherapy during OLEx studies. While these limited data are encouraging in suggesting that perampanel might be useful as a monotherapy, further studies are required to explore outcomes in a less drug-resistant population, where a larger proportion of patients might benefit from monotherapy. Seven patients with drug-resistant focal seizures Patients on adjunctive perampanel converted to perampanel monotherapy Seizure frequency was markedly reduced. Perampanel monotherapy was generally well tolerated. These limited data suggest that perampanel might be useful as a monotherapy.
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Key Words
- AMPA receptor antagonist
- AMPA, α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid
- Anti-seizure drug
- FDA, Food and Drug Administration
- OLEx, open-label extension
- SG, secondarily generalized
- Seizure frequency
- TEAE, treatment-emergent adverse event
- bid, twice daily
- qam, every morning
- qd, once daily
- qhs, every night at bedtime
- qpm, every evening
- tid, three times daily
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Affiliation(s)
- Patrick Kwan
- University of Melbourne, Royal Melbourne Hospital, Parkville, VIC 3050, Australia
- The Chinese University of Hong Kong, Shatin, NT, Hong Kong SAR, China
- Corresponding author at: Department of Neurology, Royal Melbourne Hospital, Parkville, VIC 3050, Australia.
| | - Scott Mintzer
- Thomas Jefferson University, 901 Walnut St., Philadelphia, PA 19107, USA
| | | | - Anna Patten
- Eisai Ltd., Hatfield, Hertfordshire, AL10 9SN, UK
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Li-Na Z, Deng C, Hai-Jiao W, Da X, Ge T, Ling L. Indirect comparison of third-generation antiepileptic drugs as adjunctive treatment for uncontrolled focal epilepsy. Epilepsy Res 2017; 139:60-72. [PMID: 29197667 DOI: 10.1016/j.eplepsyres.2017.11.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 11/11/2017] [Accepted: 11/20/2017] [Indexed: 02/05/2023]
Abstract
PURPOSE Eslicarbazepine (ESL), Lacosamide (LAC), Perampanel (PER) and Brivaracetam (BRV), have recently been marketed as third-generation antiepileptic drugs (AEDs). We conducted a meta-analysis to indirectly compare overall efficacy and tolerability between third-generation AEDs in uncontrolled focal epilepsy. METHODS We performed an online database search using Pubmed, Embase, Cochrane Online Library, and Clinicaltrial.gov for all available randomized controlled trials (RCTs) that investigated the therapeutic effects over a range of AED doses versus placebo. We then compared clinical efficacy and tolerability between these newer AEDs using Indirect Treatment Comparison software. RESULTS Nineteen RCTs with a total of 7245 patients were included in our study. There were no significant differences in the risk difference of 50% responder rates and seizure free rates between third generation AEDs, regardless of dose. The risk of treatment emergent adverse events was significantly higher with ESL and PER treatment compared to BRV at all doses combined. Withdrawal rates due to adverse events were also significantly higher in patients treated with the highest doses of LAC and PER versus BRV, while treatment with ESL or LAC was related to higher withdrawal rates versus BRV when all doses were combined. CONCLUSIONS Our analysis suggested there were no significant differences in efficacy between third generation AEDs in uncontrolled focal epilepsy. BRV may have the best tolerability profile. The other AEDs were associated with a higher risk for intolerable adverse, especially when taken at a high doses. The results from these indirect comparisons warrant further examination and verification through future well-designed trials.
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Affiliation(s)
- Zhu Li-Na
- Department of Neurology, West China Hospital, Sichuan University, Wai Nan Guo Xue Lane 37 #,Chengdu 610041, Sichuan, China.
| | - Chen Deng
- Department of Neurology, West China Hospital, Sichuan University, Wai Nan Guo Xue Lane 37 #,Chengdu 610041, Sichuan, China.
| | - Wang Hai-Jiao
- Department of Neurology, West China Hospital, Sichuan University, Wai Nan Guo Xue Lane 37 #,Chengdu 610041, Sichuan, China.
| | - Xu Da
- Department of Neurology, West China Hospital, Sichuan University, Wai Nan Guo Xue Lane 37 #,Chengdu 610041, Sichuan, China.
| | - Tan Ge
- Department of Neurology, West China Hospital, Sichuan University, Wai Nan Guo Xue Lane 37 #,Chengdu 610041, Sichuan, China.
| | - Liu Ling
- Department of Neurology, West China Hospital, Sichuan University, Wai Nan Guo Xue Lane 37 #,Chengdu 610041, Sichuan, China.
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Kwok CS, Johnson EL, Krauss GL. Comparing Safety and Efficacy of "Third-Generation" Antiepileptic Drugs: Long-Term Extension and Post-marketing Treatment. CNS Drugs 2017; 31:959-974. [PMID: 29204953 DOI: 10.1007/s40263-017-0480-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Four "third-generation" antiepileptic drugs (AEDs) were approved for adjunctive treatment of refractory focal onset seizures during the past 10 years. Long-term efficacy and safety of the drugs were demonstrated in large extension studies and in reports of subgroups of patients not studied in pivotal trials. Reviewing extension study and post-marketing outcome series for the four newer AEDs-lacosamide, perampanel, eslicarbazepine acetate and brivaracetam-can guide clinicians in treating and monitoring patients. AED extension studies evaluate treatment retention, drug tolerability, and drug safety during individualized treatment with flexible dosing and thus provide information not available in rigid pivotal trials. Patient retention in the studies ranged from 75 to 80% at 1 year and from 36 to 68% at 2-year treatment intervals. Safety findings were generally similar to those of pivotal trials, with no major safety risks identified and with several specific adverse drug effects, such as hyponatremia, reported. The third-generation AEDs, some through new mechanisms and others with improved tolerability compared to related AEDs, provide new options in efficacy and tolerability.
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Affiliation(s)
- Charlotte S Kwok
- Department of Neurology, Johns Hopkins University, Meyer 2-147, 600 N. Wolfe St, Baltimore, MD, 21210, USA
| | - Emily L Johnson
- Department of Neurology, Johns Hopkins University, Meyer 2-147, 600 N. Wolfe St, Baltimore, MD, 21210, USA
| | - Gregory L Krauss
- Department of Neurology, Johns Hopkins University, Meyer 2-147, 600 N. Wolfe St, Baltimore, MD, 21210, USA.
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Di Bonaventura C, Labate A, Maschio M, Meletti S, Russo E. AMPA receptors and perampanel behind selected epilepsies: current evidence and future perspectives. Expert Opin Pharmacother 2017; 18:1751-1764. [PMID: 29023170 DOI: 10.1080/14656566.2017.1392509] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA) receptors are the major mediators of glutamate-mediated excitatory neurotransmission, and are critical for synchronization and spread of epileptic activity. Areas covered: AMPA receptor antagonists have been also developed as antiepileptic drugs and perampanel (PER) is the first highly selective, non-competitive AMPA-type glutamate receptor antagonist that is available on the market. It is approved as adjunctive therapy for the treatment of partial-onset seizures with or without secondary generalization, and for primary generalized tonic-clonic seizures in idiopathic generalized epilepsy, in patients aged ≥ 12 years. This article reviews the role of AMPA receptors in the neuronal hyperexcitability underlying epilepsy, the mechanism of action and clinical experience on the anti-seizure activity of PER. Moreover, the rationale for targeting AMPA receptor in specific epileptic disorders, including brain tumor-related epilepsy, mesial temporal lobe epilepsy with/without hippocampal sclerosis, and status epilepticus is evaluated. Finally, the pharmacological rationale for the development of AMPA receptor antagonists in other neurological disorders beyond epilepsy is considered. Expert opinion: Further research aimed at better understanding the pharmacology and blocking mechanism of PER and other AMPA receptor antagonists will drive future development of therapeutic agents that target epilepsy and other neurological diseases.
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Affiliation(s)
- Carlo Di Bonaventura
- a Department of Neurology and Psychiatry, Neurology Unit , 'Sapienza' University , Rome , Italy
| | - Angelo Labate
- b Institute of Neurology , University Magna Graecia of Catanzaro , Catanzaro , Italy.,c Institute of Molecular Bioimaging and Physiology of the National Research Council , Catanzaro , Italy
| | - Marta Maschio
- d Center for Tumor-related Epilepsy, UOSD Neurology , Regina Elena National Cancer Institute , Rome , Italy
| | - Stefano Meletti
- e Department of Biomedical, Metabolic and Neural Sciences, Center for Neuroscience and Neurotechnology , University of Modena and Reggio Emilia , Modena , Italy
| | - Emilio Russo
- f Department of Science of Health, School of Medicine and Surgery , University 'Magna Graecia' of Catanzaro , Catanzaro , Italy
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Faulkner MA. Spotlight on perampanel in the management of seizures: design, development and an update on place in therapy. DRUG DESIGN DEVELOPMENT AND THERAPY 2017; 11:2921-2930. [PMID: 29042752 PMCID: PMC5634370 DOI: 10.2147/dddt.s122404] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Purpose Perampanel is a first-in-class antiepileptic medication approved for the treatment of partial (focal) seizures, and as adjunctive treatment for primarily generalized tonic–clonic seizures. The pharmacology, efficacy data, adverse-effect profile, pharmacokinetics and place in therapy are reviewed. Summary Perampanel is indicated for use in patients with epilepsy who are 12 years of age or older. It is the first medication designed specifically to be a non-competitive antagonist at post-synaptic α-amino-3-hydroxyl-5-methyl-4-isoxazole-propionate receptors. Efficacy in refractory seizures has been established, and ongoing efficacy demonstrated by post-marketing data. The drug is completely absorbed, and exhibits a half-life that allows for once-daily administration in doses up to 12 mg/day. Drug interactions are minimal, but increased doses may be necessary when given with strong inducers of cytochrome P450 enzymes, including when perampanel is co-administered with other antiepileptics that exhibit this property. The most common adverse effects noted in both clinical trials and post-marketing are dizziness and somnolence. Psychiatric and behavioral adverse events have been documented in both adult and pediatric patients, including those with no corresponding diagnostic history. Conclusion Perampanel is a novel adjunctive antiepileptic medication that is an effective option for adolescents and adults with partial seizures, and primarily generalized tonic–clonic seizures uncontrolled with other medications.
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Affiliation(s)
- Michele A Faulkner
- Department of Pharmacy Practice.,Department of Neurology, Creighton University Schools of Pharmacy and Medicine, Omaha, NE, USA
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Zhu LN, Chen D, Xu D, Tan G, Wang HJ, Liu L. Newer antiepileptic drugs compared to levetiracetam as adjunctive treatments for uncontrolled focal epilepsy: An indirect comparison. Seizure 2017; 51:121-132. [PMID: 28854405 DOI: 10.1016/j.seizure.2017.07.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 07/26/2017] [Accepted: 07/29/2017] [Indexed: 02/05/2023] Open
Abstract
PURPOSE Newer antiepileptic drugs (AEDs), such as Eslicarbazepine (ESL), Lacosamide (LAC), Perampanel (PER) and Brivaracetam (BRV), have been marketed as adjunctive treatments for partial-onset seizures. Our aim was to compare the efficacy and tolerability of newer AEDs with Levetiracetam (LEV), when used as add-on treatments for uncontrolled focal epilepsy. METHOD We conducted an online database search on PubMed, Embase, Cochrane Online Library and Clinicaltrials.gov for all available randomized controlled trials (RCTs) investigating the therapeutic effects of newer AEDs or LEV vs placebo. Indirect comparisons for clinical efficacy and tolerability at different doses between the newer AEDs and LEV were then performed using Indirect Treatment Comparison (ITC) software. RESULTS Twenty-four RCTs with a total of 8540 patients were included. Compared to LEV, ESL, LAC and BRV did not showed significant difference in efficacy at all dose level. PER showed lower 50% response rates and seizure-free rates at the highest effective recommended dosages. Treatment-emergent adverse events (TEAEs) and withdrawal rates due to adverse events (AEs) of LAC and PER were higher than LEV at the highest effective recommended dosages, and overall AE rates from ESL were higher than LEV. CONCLUSIONS Indirect comparisons suggested that ESL, LAC and BRV were not inferior to LEV in efficacy. ESL, LAC and PER may have a possible worse tolerability profile compared to LEV at high dose. But BRV may exhibit a similar tolerability to LEV. Newer AEDs cannot exceed the LEV on efficacy and tolerability.
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Affiliation(s)
- Li-Na Zhu
- Department of Neurology, West China Hospital, Sichuan University, Wai Nan Guo Xue Lane 37 #, Chengdu 610041, Sichuan, China.
| | - Deng Chen
- Department of Neurology, West China Hospital, Sichuan University, Wai Nan Guo Xue Lane 37 #, Chengdu 610041, Sichuan, China.
| | - Da Xu
- Department of Neurology, West China Hospital, Sichuan University, Wai Nan Guo Xue Lane 37 #, Chengdu 610041, Sichuan, China.
| | - Ge Tan
- Department of Neurology, West China Hospital, Sichuan University, Wai Nan Guo Xue Lane 37 #, Chengdu 610041, Sichuan, China.
| | - Hai-Jiao Wang
- Department of Neurology, West China Hospital, Sichuan University, Wai Nan Guo Xue Lane 37 #, Chengdu 610041, Sichuan, China.
| | - Ling Liu
- Department of Neurology, West China Hospital, Sichuan University, Wai Nan Guo Xue Lane 37 #, Chengdu 610041, Sichuan, China.
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Brodie MJ, Besag F, Ettinger AB, Mula M, Gobbi G, Comai S, Aldenkamp AP, Steinhoff BJ. Epilepsy, Antiepileptic Drugs, and Aggression: An Evidence-Based Review. Pharmacol Rev 2017; 68:563-602. [PMID: 27255267 PMCID: PMC4931873 DOI: 10.1124/pr.115.012021] [Citation(s) in RCA: 146] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Antiepileptic drugs (AEDs) have many benefits but also many side effects, including aggression, agitation, and irritability, in some patients with epilepsy. This article offers a comprehensive summary of current understanding of aggressive behaviors in patients with epilepsy, including an evidence-based review of aggression during AED treatment. Aggression is seen in a minority of people with epilepsy. It is rarely seizure related but is interictal, sometimes occurring as part of complex psychiatric and behavioral comorbidities, and it is sometimes associated with AED treatment. We review the common neurotransmitter systems and brain regions implicated in both epilepsy and aggression, including the GABA, glutamate, serotonin, dopamine, and noradrenaline systems and the hippocampus, amygdala, prefrontal cortex, anterior cingulate cortex, and temporal lobes. Few controlled clinical studies have used behavioral measures to specifically examine aggression with AEDs, and most evidence comes from adverse event reporting from clinical and observational studies. A systematic approach was used to identify relevant publications, and we present a comprehensive, evidence-based summary of available data surrounding aggression-related behaviors with each of the currently available AEDs in both adults and in children/adolescents with epilepsy. A psychiatric history and history of a propensity toward aggression/anger should routinely be sought from patients, family members, and carers; its presence does not preclude the use of any specific AEDs, but those most likely to be implicated in these behaviors should be used with caution in such cases.
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Affiliation(s)
- Martin J Brodie
- Epilepsy Unit, West Glasgow Ambulatory Care Hospital-Yorkhill, Glasgow, Scotland (M.J.B.); East London National Health Service Foundation Trust, Bedford, United Kingdom (F.B.); University College London School of Pharmacy, London, United Kingdom (F.B.); Winthrop University Hospital, Mineola, New York (A.B.E.); Epilepsy Group, Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom (M.M.); Institute of Medical and Biomedical Sciences, St. George's, University of London, London, United Kingdom (M.M.); Neurobiological Psychiatry Unit, Department of Psychiatry, McGill University, Montreal, Quebec, Canada (G.G., S.C.); McGill University Health Center, McGill University, Montreal, Quebec, Canada (G.G., S.C.); Division of Neuroscience, San Raffaele Scientific Institute and Vita-Salute University, Milan, Italy (S.C.); Epilepsy Centre Kempenhaeghe, Heeze, The Netherlands (A.P.A.); Maastricht University Medical Centre, Maastricht, The Netherlands (A.P.A.); and Kork Epilepsy Centre, Kehl-Kork, Germany (B.J.S.)
| | - Frank Besag
- Epilepsy Unit, West Glasgow Ambulatory Care Hospital-Yorkhill, Glasgow, Scotland (M.J.B.); East London National Health Service Foundation Trust, Bedford, United Kingdom (F.B.); University College London School of Pharmacy, London, United Kingdom (F.B.); Winthrop University Hospital, Mineola, New York (A.B.E.); Epilepsy Group, Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom (M.M.); Institute of Medical and Biomedical Sciences, St. George's, University of London, London, United Kingdom (M.M.); Neurobiological Psychiatry Unit, Department of Psychiatry, McGill University, Montreal, Quebec, Canada (G.G., S.C.); McGill University Health Center, McGill University, Montreal, Quebec, Canada (G.G., S.C.); Division of Neuroscience, San Raffaele Scientific Institute and Vita-Salute University, Milan, Italy (S.C.); Epilepsy Centre Kempenhaeghe, Heeze, The Netherlands (A.P.A.); Maastricht University Medical Centre, Maastricht, The Netherlands (A.P.A.); and Kork Epilepsy Centre, Kehl-Kork, Germany (B.J.S.)
| | - Alan B Ettinger
- Epilepsy Unit, West Glasgow Ambulatory Care Hospital-Yorkhill, Glasgow, Scotland (M.J.B.); East London National Health Service Foundation Trust, Bedford, United Kingdom (F.B.); University College London School of Pharmacy, London, United Kingdom (F.B.); Winthrop University Hospital, Mineola, New York (A.B.E.); Epilepsy Group, Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom (M.M.); Institute of Medical and Biomedical Sciences, St. George's, University of London, London, United Kingdom (M.M.); Neurobiological Psychiatry Unit, Department of Psychiatry, McGill University, Montreal, Quebec, Canada (G.G., S.C.); McGill University Health Center, McGill University, Montreal, Quebec, Canada (G.G., S.C.); Division of Neuroscience, San Raffaele Scientific Institute and Vita-Salute University, Milan, Italy (S.C.); Epilepsy Centre Kempenhaeghe, Heeze, The Netherlands (A.P.A.); Maastricht University Medical Centre, Maastricht, The Netherlands (A.P.A.); and Kork Epilepsy Centre, Kehl-Kork, Germany (B.J.S.)
| | - Marco Mula
- Epilepsy Unit, West Glasgow Ambulatory Care Hospital-Yorkhill, Glasgow, Scotland (M.J.B.); East London National Health Service Foundation Trust, Bedford, United Kingdom (F.B.); University College London School of Pharmacy, London, United Kingdom (F.B.); Winthrop University Hospital, Mineola, New York (A.B.E.); Epilepsy Group, Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom (M.M.); Institute of Medical and Biomedical Sciences, St. George's, University of London, London, United Kingdom (M.M.); Neurobiological Psychiatry Unit, Department of Psychiatry, McGill University, Montreal, Quebec, Canada (G.G., S.C.); McGill University Health Center, McGill University, Montreal, Quebec, Canada (G.G., S.C.); Division of Neuroscience, San Raffaele Scientific Institute and Vita-Salute University, Milan, Italy (S.C.); Epilepsy Centre Kempenhaeghe, Heeze, The Netherlands (A.P.A.); Maastricht University Medical Centre, Maastricht, The Netherlands (A.P.A.); and Kork Epilepsy Centre, Kehl-Kork, Germany (B.J.S.)
| | - Gabriella Gobbi
- Epilepsy Unit, West Glasgow Ambulatory Care Hospital-Yorkhill, Glasgow, Scotland (M.J.B.); East London National Health Service Foundation Trust, Bedford, United Kingdom (F.B.); University College London School of Pharmacy, London, United Kingdom (F.B.); Winthrop University Hospital, Mineola, New York (A.B.E.); Epilepsy Group, Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom (M.M.); Institute of Medical and Biomedical Sciences, St. George's, University of London, London, United Kingdom (M.M.); Neurobiological Psychiatry Unit, Department of Psychiatry, McGill University, Montreal, Quebec, Canada (G.G., S.C.); McGill University Health Center, McGill University, Montreal, Quebec, Canada (G.G., S.C.); Division of Neuroscience, San Raffaele Scientific Institute and Vita-Salute University, Milan, Italy (S.C.); Epilepsy Centre Kempenhaeghe, Heeze, The Netherlands (A.P.A.); Maastricht University Medical Centre, Maastricht, The Netherlands (A.P.A.); and Kork Epilepsy Centre, Kehl-Kork, Germany (B.J.S.)
| | - Stefano Comai
- Epilepsy Unit, West Glasgow Ambulatory Care Hospital-Yorkhill, Glasgow, Scotland (M.J.B.); East London National Health Service Foundation Trust, Bedford, United Kingdom (F.B.); University College London School of Pharmacy, London, United Kingdom (F.B.); Winthrop University Hospital, Mineola, New York (A.B.E.); Epilepsy Group, Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom (M.M.); Institute of Medical and Biomedical Sciences, St. George's, University of London, London, United Kingdom (M.M.); Neurobiological Psychiatry Unit, Department of Psychiatry, McGill University, Montreal, Quebec, Canada (G.G., S.C.); McGill University Health Center, McGill University, Montreal, Quebec, Canada (G.G., S.C.); Division of Neuroscience, San Raffaele Scientific Institute and Vita-Salute University, Milan, Italy (S.C.); Epilepsy Centre Kempenhaeghe, Heeze, The Netherlands (A.P.A.); Maastricht University Medical Centre, Maastricht, The Netherlands (A.P.A.); and Kork Epilepsy Centre, Kehl-Kork, Germany (B.J.S.)
| | - Albert P Aldenkamp
- Epilepsy Unit, West Glasgow Ambulatory Care Hospital-Yorkhill, Glasgow, Scotland (M.J.B.); East London National Health Service Foundation Trust, Bedford, United Kingdom (F.B.); University College London School of Pharmacy, London, United Kingdom (F.B.); Winthrop University Hospital, Mineola, New York (A.B.E.); Epilepsy Group, Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom (M.M.); Institute of Medical and Biomedical Sciences, St. George's, University of London, London, United Kingdom (M.M.); Neurobiological Psychiatry Unit, Department of Psychiatry, McGill University, Montreal, Quebec, Canada (G.G., S.C.); McGill University Health Center, McGill University, Montreal, Quebec, Canada (G.G., S.C.); Division of Neuroscience, San Raffaele Scientific Institute and Vita-Salute University, Milan, Italy (S.C.); Epilepsy Centre Kempenhaeghe, Heeze, The Netherlands (A.P.A.); Maastricht University Medical Centre, Maastricht, The Netherlands (A.P.A.); and Kork Epilepsy Centre, Kehl-Kork, Germany (B.J.S.)
| | - Bernhard J Steinhoff
- Epilepsy Unit, West Glasgow Ambulatory Care Hospital-Yorkhill, Glasgow, Scotland (M.J.B.); East London National Health Service Foundation Trust, Bedford, United Kingdom (F.B.); University College London School of Pharmacy, London, United Kingdom (F.B.); Winthrop University Hospital, Mineola, New York (A.B.E.); Epilepsy Group, Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom (M.M.); Institute of Medical and Biomedical Sciences, St. George's, University of London, London, United Kingdom (M.M.); Neurobiological Psychiatry Unit, Department of Psychiatry, McGill University, Montreal, Quebec, Canada (G.G., S.C.); McGill University Health Center, McGill University, Montreal, Quebec, Canada (G.G., S.C.); Division of Neuroscience, San Raffaele Scientific Institute and Vita-Salute University, Milan, Italy (S.C.); Epilepsy Centre Kempenhaeghe, Heeze, The Netherlands (A.P.A.); Maastricht University Medical Centre, Maastricht, The Netherlands (A.P.A.); and Kork Epilepsy Centre, Kehl-Kork, Germany (B.J.S.)
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The Orally Active Noncompetitive AMPAR Antagonist Perampanel Attenuates Focal Cerebral Ischemia Injury in Rats. Cell Mol Neurobiol 2017; 38:459-466. [PMID: 28401316 DOI: 10.1007/s10571-017-0489-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 03/24/2017] [Indexed: 02/07/2023]
Abstract
Inhibition of ionotropic glutamate receptors (iGluRs) is a potential target of therapy for ischemic stroke. Perampanel is a potent noncompetitive α-amino-3-hydroxy-5-methyl-4-isoxazole propionate receptor (AMPAR) antagonist with good oral bioavailability and favorable pharmacokinetic properties. Here, we investigated the potential protective effects of perampanel against focal cerebral ischemia in a middle cerebral artery occlusion (MCAO) model in rats. Oral administration with perampanel significantly reduced MCAO-induced brain edema, brain infarct volume, and neuronal apoptosis. These protective effects were associated with improved functional outcomes, as measured by foot-fault test, adhesive removal test, and modified neurological severity score (mNSS) test. Importantly, perampanel was effective even when the administration was delayed to 1 h after reperfusion. The results of enzyme-linked immunosorbent assay (ELISA) showed that perampanel significantly decreased the expression of pro-inflammatory cytokines IL-1β and TNF-α, whereas it increased the levels of anti-inflammatory cytokines IL-10 and TGF-β1 after MCAO. In addition, perampanel treatment markedly decreased the expression of inducible nitric oxide synthase (iNOS) and neuronal nitric oxide synthase (nNOS), and also inhibited nitric oxide (NO) generation in MCAO-injured rats at 24 and 72 h after reperfusion. In conclusion, this study demonstrated that the orally active AMPAR antagonist perampanel protects against experimental ischemic stroke via regulating inflammatory cytokines and NOS pathways.
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Heyman E, Lahat E, Levin N, Epstein O, Lazinger M, Berkovitch M, Gandelman-Marton R. Tolerability and efficacy of perampanel in children with refractory epilepsy. Dev Med Child Neurol 2017; 59:441-444. [PMID: 27935018 DOI: 10.1111/dmcn.13362] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/28/2016] [Indexed: 12/19/2022]
Abstract
AIM There are few reports on the tolerability and efficacy of perampanel, a new antiepileptic drug with a novel mechanism of action, in children and adolescents. We aimed to describe our experience with perampanel add-on and mono-therapy in children with refractory epilepsy. METHOD Computerized medical records of children treated with perampanel in the paediatric neurology clinic from December 2012 to October 2015 were reviewed. RESULTS Twenty-four children treated with perampanel (15 females, 9 males) aged 1 year 6 months to 17 years (mean 10y, standard deviation [SD] 4y 5mo) were identified. Adverse events were more common in children aged 12 years or older (89%) compared to younger children (53%), and were mainly behavioural. Ten (42%) children had 50 per cent or higher seizure reduction, two (8%) children had 33 per cent seizure reduction, and seizures were less severe in one (4%) child. Perampanel was discontinued in 13 (54%) children mostly due to adverse events. The mean duration of follow-up in the remaining 11 children was 8.1 months (SD 5.2) (range 1.3-17mo). INTERPRETATION Perampanel is associated with a relatively high rate of behavioural adverse events mostly in adolescents with refractory epilepsy.
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Affiliation(s)
- Eli Heyman
- Department of Pediatric Neurology, Assaf Harofeh Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eli Lahat
- Department of Pediatric Neurology, Assaf Harofeh Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noa Levin
- Department of Pediatric Neurology, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Orna Epstein
- Department of Pediatric Neurology, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Mirit Lazinger
- Department of Pediatric Neurology, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Matitiahu Berkovitch
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Clinical Pharmacology Unit, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Revital Gandelman-Marton
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Electroencephalography Laboratory, Assaf Harofeh Medical Center, Zerifin, Israel
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Brigo F, Bragazzi NL, Nardone R, Trinka E. Efficacy and tolerability of brivaracetam compared to lacosamide, eslicarbazepine acetate, and perampanel as adjunctive treatments in uncontrolled focal epilepsy: Results of an indirect comparison meta-analysis of RCTs. Seizure 2016; 42:29-37. [PMID: 27710868 DOI: 10.1016/j.seizure.2016.08.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 08/21/2016] [Accepted: 08/27/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Brivaracetam (BRV), eslicarbazepine acetate (ESL), lacosamide (LCM), and perampanel (PER) have been recently marketed as adjunctive treatments for focal onset seizures. To date, no randomized controlled trial (RCT) has directly compared BRV with ESL, LCM, or PER. PURPOSE To compare BRV with the other add-on AEDs in patients with uncontrolled focal epilepsy, estimating their efficacy and tolerability through an adjusted, common-reference based indirect comparison meta-analysis. METHODS We systematically searched RCTs in which add-on treatment with ESL or LCM in patients with focal onset seizures have been compared with placebo. Efficacy and tolerability outcomes were considered. Random-effects Mantel-Haenszel meta-analyses were performed to obtain odds ratios (ORs) for the efficacy of BRV, LCM, ESL, or PER versus placebo. Adjusted indirect comparisons were then made between BRV and the other three AEDs using the obtained results, comparing the minimum and the highest effective recommended daily dose of each drug. RESULTS Seventeen RCTs, with a total of 4971 patients were included. After adjusting for dose-effects, indirect comparisons showed no difference between BRV and LCM, ESL, or PER for responder rate and seizure freedom. Lower adverse events were observed with high dose BRV compared to high dose ESL or PER, but no difference was found in withdrawing because of adverse events. CONCLUSIONS Indirect comparisons do not demonstrate a significant difference in efficacy between add-on BRV and LCM, ESL, or PER in focal epilepsy, and might suggest a better tolerability of BRV than ESL, and possibly also PER, at the highest effective recommended dose.
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Affiliation(s)
- Francesco Brigo
- Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Italy; Division of Neurology, Franz Tappeiner Hospital, Merano, Italy.
| | - Nicola Luigi Bragazzi
- School of Public Health, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy; Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Section of Psychiatry, University of Genoa, Genoa, Italy
| | - Raffaele Nardone
- Division of Neurology, Franz Tappeiner Hospital, Merano, Italy; Department of Neurology, Christian Doppler Medical Centre, Paracelsus Medical University, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Medical Centre, Paracelsus Medical University, Salzburg, Austria; Center for Cognitive Neuroscience, Salzburg, Austria; University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
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Abstract
Perampanel (Fycompa®), an orally-active, selective, noncompetitive α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor antagonist, is a first-in-class antiepileptic drug (AED) offering the convenience of once-daily administration. In the EU and US, perampanel is approved in patients with epilepsy aged ≥12 years for the adjunctive treatment of primary generalized tonic-clonic seizures (GTCS) and partial-onset seizures (POS; with or without secondary generalization). In phase III trials of 17 or 19 weeks' duration, add-on perampanel ≤12 mg/day significantly improved seizure control in patients aged ≥12 years who were experiencing either primary GTCS or POS (with or without secondary generalization), despite ongoing treatment with stable dosages of one to three AEDs. Improvements in seizure control were maintained for up to 2 years in extensions of these core studies. Perampanel also provided sustained seizure control for up to ≈4 years in an extension of two phase II studies in patients aged ≥18 years with drug-resistant POS. Adjunctive perampanel therapy was generally well tolerated. Treatment-emergent adverse events were most commonly CNS-related (e.g. dizziness, somnolence, fatigue and irritability) and dose-related; however, most were of mild to moderate intensity. Clinical experience with perampanel is accumulating, although comparative studies and pharmacoeconomic data that could assist in positioning it relative to other AEDS that are approved and/or recommended as adjunctive therapy are lacking. Nonetheless, on the basis of its overall clinical profile and unique mechanism of action, perampanel is a useful additional adjunctive treatment option for patients with drug-resistant POS, with or without secondary generalization, and primary GTCS.
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Affiliation(s)
- James E Frampton
- Springer, Private Bag 65901, Mairangi Bay 0754, Auckland, New Zealand.
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Rudzinski LA, Vélez-Ruiz NJ, Gedzelman ER, Mauricio EA, Shih JJ, Karakis I. New antiepileptic drugs: focus on ezogabine, clobazam, and perampanel. J Investig Med 2016; 64:1087-101. [DOI: 10.1136/jim-2016-000151] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2016] [Indexed: 12/17/2022]
Abstract
Ezogabine, clobazam, and perampanel are among the newest antiseizure drugs approved by the Food and Drug Administration between 2011 and 2012. Ezogabine and perampanel are approved for adjunctive treatment of partial epilepsy. Perampanel is also approved for adjunctive treatment of primary generalized tonic–clonic seizures. Ezogabine and perampanel have novel mechanisms of action. Ezogabine binds to voltage-gated potassium channels and increases the M-current thereby causing membrane hyperpolarization. Perampanel is a selective, non-competitive 2-amino-3-(3-hydroxy-5-methyl-isoxazol-4-yl)propanoic acid receptor antagonist, which reduces neuronal excitation. Clobazam has been used worldwide since the 1970s and is approved for adjunctive treatment of seizures associated with Lennox-Gastaut syndrome. Clobazam is the only 1,5-benzodiazepine currently in clinical use, which is less sedating than the commonly used 1,4-benzodiazepines. Phase III multicenter, randomized, double-blind, placebo-controlled trials demonstrated efficacy and good tolerability of these 3 new antiepileptic drugs. These drugs represent a welcome addition to the armamentarium of practitioners, but it remains to be seen how they will affect the landscape of pharmacoresistant epilepsy.
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Trinka E, Steinhoff BJ, Nikanorova M, Brodie MJ. Perampanel for focal epilepsy: insights from early clinical experience. Acta Neurol Scand 2016; 133:160-72. [PMID: 26506904 PMCID: PMC4738453 DOI: 10.1111/ane.12529] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2015] [Indexed: 12/25/2022]
Abstract
Perampanel is approved for adjunctive therapy of focal epilepsy with or without secondarily generalized seizures in patients aged >12 years. This narrative review uses real-world and clinical trial data to elucidate perampanel's role in the clinic. Audit data show good tolerability with perampanel and higher freedom-from-seizure rates in elderly vs younger patients. When using perampanel in elderly patients, special attention should be given to comorbidities and co-medication to avoid potential interactions or adverse events. Slower titration is generally recommended, and seizure control should be reassessed at a dose of 4 mg before further dose increases. Perampanel efficacy is similar in adolescents and adults; however, somnolence, nasopharyngitis, and aggression are more frequent in adolescents vs the overall population. Individualized and slow-dose titration can minimize adverse events. Low serum concentrations of perampanel may occur in patients also receiving some enzyme-inducing anti-epileptic drugs; a perampanel dose increase may be required. Adverse events of importance with perampanel include dizziness; anger, aggression, and hostile behavior (particularly in adolescents); and falls (particularly in patients >65 years). An individualized approach to dosing, including slower up-titration and bedtime dosing, reduces dizziness risk. Other drugs may cause or aggravate dizziness; reducing concomitant drugs may be necessary when up-titrating perampanel. It would seem clinically appropriate to give due consideration to avoiding use in patients with a history of anger or hostile/aggressive behavior. The possibility of such behaviors should be discussed with patients before starting perampanel, with monitoring during up-titration. Slower up-titration of perampanel in older patients helps reduce fall risk.
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Affiliation(s)
- E. Trinka
- Department of Neurology Christian Doppler Medical at the Paracelsus Medical University Salzburg Centre for Cognitive Neuroscience Salzburg Austria
| | | | - M. Nikanorova
- Children's Department Danish Epilepsy Centre Dianalund Denmark
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Besag FM, Patsalos PN. Clinical efficacy of perampanel for partial-onset and primary generalized tonic-clonic seizures. Neuropsychiatr Dis Treat 2016; 12:1215-20. [PMID: 27274257 PMCID: PMC4876101 DOI: 10.2147/ndt.s83842] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND PURPOSE Perampanel, a selective noncompetitive antagonist at the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor, is highly effective in a wide range of experimental models. Although initially licensed as adjunctive therapy for partial seizures with or without secondary generalization in patients aged 12 years or older, the US Food and Drug Administration has recently approved its use in the treatment of primary generalized tonic-clonic seizures (PGTCS). This paper reviews the pharmacokinetics, efficacy, and tolerability of perampanel as an antiepileptic drug. RESULTS After oral ingestion, perampanel is rapidly absorbed (T max, 0.5-2.5 hours), has a bioavailability of ~100%, and is highly protein bound (~95%) in plasma. It undergoes extensive (>90%) hepatic metabolism, primarily via cytochrome P450 3A4 (CYP3A4), with a half-life of 48 hours. Carbamazepine and other antiepileptic drugs can enhance its metabolism via induction of CYP3A4. Efficacy of perampanel in focal seizures has been extensively evaluated in Phase II and randomized, placebo-controlled Phase III trials. The efficacy in PGTCS has been reported in one class I study. In the treatment of focal seizures, perampanel showed significant dose-dependent median seizure reductions: 4 mg/d, 23%; 8 mg/d, 26%-31%; 12 mg/d, 18%-35%; and placebo, 10%-21%. The 50% responder rates were 15%-26%, 29%, 33%-38%, and 34%-36% for placebo, 4 mg/d, 8 mg/d, and 12 mg/d perampanel, respectively. Freedom from seizures was recorded in 0%-1.7% of the placebo group, 1.9% of the 2 mg group, 2.6%-4.4% of the 8 mg group, and 2.6%-6.5% of the 12 mg group. For PGTCS, the median seizure reduction was 76.5% for perampanel and 38.4% for placebo. The 50% responder rate was 64.2% for perampanel and 39.5% for placebo. Seizure freedom during maintenance phase was 30.9% for perampanel and 12.3% for placebo. Adverse effects included dose-dependent increases in the frequency of dizziness, somnolence, fatigue, irritability, falls, and probably nausea. CONCLUSION Perampanel is effective in treating both partial-onset seizures and PGTCS.
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Affiliation(s)
- Frank Mc Besag
- East London Foundation NHS Trust, NIHR University College London Hospitals Biomedical Research Centre, London, UK; Institute of Psychiatry, Psychology and Neuroscience, NIHR University College London Hospitals Biomedical Research Centre, London, UK; UCL School of Pharmacy, NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Philip N Patsalos
- Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, NIHR University College London Hospitals Biomedical Research Centre, London, UK; Epilepsy Society, Chalfont Centre for Epilepsy, Chalfont St Peter, UK
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Strzelczyk A, Willems LM, Willig S, Rosenow F, Bauer S. Perampanel in the treatment of focal and idiopathic generalized epilepsies and of status epilepticus. Expert Rev Clin Pharmacol 2015; 8:733-40. [DOI: 10.1586/17512433.2015.1091303] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Palleria C, Coppola A, Citraro R, Del Gaudio L, Striano S, De Sarro G, Russo E. Perspectives on treatment options for mesial temporal lobe epilepsy with hippocampal sclerosis. Expert Opin Pharmacother 2015; 16:2355-71. [PMID: 26328621 DOI: 10.1517/14656566.2015.1084504] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Mesial temporal lobe epilepsy associated with hippocampal sclerosis (MTLE-HS) is a syndrome that is often refractory to drug treatment. The effects on specific syndromes are not currently available from the pre-marketing clinical development of new AEDs; this does not allow the prediction of whether new drugs will be more effective in the treatment of some patients. AREAS COVERED We have reviewed all the existing literature relevant to the understanding of a potential effectiveness in MTLE-HS patients for the latest AEDs, namely brivaracetam, eslicarbazepine, lacosamide, perampanel and retigabine also including the most relevant clinical data and a brief description of their pharmacological profile. Records were identified using predefined search criteria using electronic databases (e.g., PubMed, Cochrane Library Database of Systematic Reviews). Primary peer-reviewed articles published up to the 15 June 2015 were included. EXPERT OPINION All the drugs considered have the potential to be effective in the treatment of MTLE-HS; in fact, they possess proven efficacy in animal models; currently considered valuable tools for predicting drug efficacy in TLE. Furthermore, for some of these (e.g., lacosamide and eslicarbazepine) data are already available from post-marketing studies while brivaracetam acting on SV2A like levetiracetam might have the same potential effectiveness with the possibility to be more efficacious considering its ability to inhibit voltage gated sodium channels; finally, perampanel and retigabine are very effective drugs in animal models of TLE.
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Affiliation(s)
- Caterina Palleria
- a 1 University of Catanzaro, Science of Health Department, School of Medicine , Naples, Italy +39 0 96 13 69 41 91 ; +39 0 96 13 69 41 92 ;
| | - Antonietta Coppola
- b 2 Federico II University, Epilepsy Centre, Reproductive and Odontostomatological Sciences, Department of Neuroscience , Naples, Italy
| | - Rita Citraro
- a 1 University of Catanzaro, Science of Health Department, School of Medicine , Naples, Italy +39 0 96 13 69 41 91 ; +39 0 96 13 69 41 92 ;
| | - Luigi Del Gaudio
- b 2 Federico II University, Epilepsy Centre, Reproductive and Odontostomatological Sciences, Department of Neuroscience , Naples, Italy
| | - Salvatore Striano
- b 2 Federico II University, Epilepsy Centre, Reproductive and Odontostomatological Sciences, Department of Neuroscience , Naples, Italy
| | - Giovambattista De Sarro
- a 1 University of Catanzaro, Science of Health Department, School of Medicine , Naples, Italy +39 0 96 13 69 41 91 ; +39 0 96 13 69 41 92 ;
| | - Emilio Russo
- a 1 University of Catanzaro, Science of Health Department, School of Medicine , Naples, Italy +39 0 96 13 69 41 91 ; +39 0 96 13 69 41 92 ;
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Ettinger AB, LoPresti A, Yang H, Williams B, Zhou S, Fain R, Laurenza A. Psychiatric and behavioral adverse events in randomized clinical studies of the noncompetitive AMPA receptor antagonist perampanel. Epilepsia 2015; 56:1252-63. [PMID: 26140524 PMCID: PMC4758397 DOI: 10.1111/epi.13054] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2015] [Indexed: 11/27/2022]
Abstract
Objective Perampanel, a selective, noncompetitive α‐amino‐3‐hydroxy‐5‐methyl‐4‐isoxazolepropionic acid (AMPA) glutamate receptor antagonist, is indicated for adjunctive treatment of partial seizures in patients ≥12 years based on three phase III clinical studies. The perampanel U.S. Prescribing Information includes a boxed warning for serious psychiatric and behavioral adverse reactions. To provide context for this warning, detail on psychiatric and behavioral safety data from perampanel clinical studies is presented. Methods An analysis of pooled safety data from three phase III studies in patients with partial seizures is presented. Data from phase I and phase II studies in patients with and without epilepsy were also analyzed. Psychiatric and behavioral treatment‐emergent adverse events (TEAEs) were evaluated according to Medical Dictionary for Regulatory Activities (MedDRA) terms, using “narrow” and “narrow‐and‐broad” standardized MedDRA queries (SMQs) for TEAEs suggestive of hostility/aggression. Results From the three phase III partial‐seizure studies, the overall rate of psychiatric TEAEs was higher in the 8 mg (17.2%) and 12 mg (22.4%) perampanel groups versus placebo (12.4%). In the “narrow” SMQ, hostility/aggression TEAEs were observed in 2.8% for 8 mg and 6.3% for 12 mg perampanel groups, versus 0.7% of placebo patients. “Narrow‐and‐broad” SMQs for hostility/aggression TEAE rates were 12.3% for 8 mg and 20.4% for 12 mg perampanel groups, versus 5.7% for placebo; rates for events resulting in discontinuation were perampanel = 1.6% versus placebo = 0.7%. For events reported as serious AEs (SAEs), rates were perampanel = 0.7% versus placebo = 0.2%. In nonepilepsy patients, psychiatric TEAEs were similar between patients receiving perampanel and placebo. In phase I subjects/volunteers, all psychiatric TEAEs were mild or moderate. These analyses suggest that psychiatric adverse effects are associated with use of perampanel. Significance Patients and caregivers should be counseled regarding the potential risk of psychiatric and behavioral events with perampanel in patients with partial seizures; patients should be monitored for these events during treatment, especially during titration and at higher doses.
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Affiliation(s)
- Alan B Ettinger
- Department of Clinical Neurology, Albert Einstein College of Medicine, Bronx, New York, U.S.A
| | - Antonia LoPresti
- Eisai Medical and Scientific Affairs, Eisai Inc., Woodcliff Lake, New Jersey, U.S.A
| | - Haichen Yang
- Eisai Neuroscience and General Medicine PCU, Eisai Inc., Woodcliff Lake, New Jersey, U.S.A
| | - Betsy Williams
- Eisai Medical and Scientific Affairs, Eisai Inc., Woodcliff Lake, New Jersey, U.S.A
| | - Sharon Zhou
- Eisai Medical and Scientific Affairs, Eisai Inc., Woodcliff Lake, New Jersey, U.S.A
| | - Randi Fain
- Eisai Medical and Scientific Affairs, Eisai Inc., Woodcliff Lake, New Jersey, U.S.A
| | - Antonio Laurenza
- Eisai Neuroscience and General Medicine PCU, Eisai Inc., Woodcliff Lake, New Jersey, U.S.A
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Steinhoff BJ. The AMPA receptor antagonist perampanel in the adjunctive treatment of partial-onset seizures: clinical trial evidence and experience. Ther Adv Neurol Disord 2015; 8:137-47. [PMID: 25941541 DOI: 10.1177/1756285615575696] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
More than 20 antiepileptic drugs (AEDs) are currently available for the medical treatment of epilepsies. However, still about 30% of all epilepsies have a drug-resistant course. Even worse, in the case of some epilepsy syndromes, freedom from seizures is almost never achieved. Therefore, new treatment options are still necessary, especially if theoretical concepts such as a new mode of action offer new horizons. Perampanel is the first-in-class orally active, selective, noncompetitive antagonist of α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors. The pharmacokinetic profile offers once-daily dosing in the evening as the best route of administration. According to the results of three pivotal placebo-controlled, double-blind phase III trials that investigated perampanel as an adjunctive AED in adult and adolescent patients from age 12 years who had ongoing focal epileptic seizures despite receiving one to three AEDs, perampanel has been widely licensed and introduced. Phase III trials showed superiority of adjunctive perampanel over placebo consistently in the range between 4 and 12 mg. Dizziness and somnolence were by far the leading adverse events. This review covers the clinical trial evidence but also clinical experience with perampanel after launch according to observational studies.
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Affiliation(s)
- Bernhard J Steinhoff
- Kork Epilepsy Centre, Epilepsiezentrum Kork, Landstraße 1, 77694 Kehl-Kork, Germany
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Napier RJ, Norris BA, Swimm A, Giver CR, Harris WAC, Laval J, Napier BA, Patel G, Crump R, Peng Z, Bornmann W, Pulendran B, Buller RM, Weiss DS, Tirouvanziam R, Waller EK, Kalman D. Low doses of imatinib induce myelopoiesis and enhance host anti-microbial immunity. PLoS Pathog 2015; 11:e1004770. [PMID: 25822986 PMCID: PMC4379053 DOI: 10.1371/journal.ppat.1004770] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 02/27/2015] [Indexed: 01/10/2023] Open
Abstract
Imatinib mesylate (Gleevec) inhibits Abl1, c-Kit, and related protein tyrosine kinases (PTKs) and serves as a therapeutic for chronic myelogenous leukemia and gastrointestinal stromal tumors. Imatinib also has efficacy against various pathogens, including pathogenic mycobacteria, where it decreases bacterial load in mice, albeit at doses below those used for treating cancer. We report that imatinib at such low doses unexpectedly induces differentiation of hematopoietic stem cells and progenitors in the bone marrow, augments myelopoiesis but not lymphopoiesis, and increases numbers of myeloid cells in blood and spleen. Whereas progenitor differentiation relies on partial inhibition of c-Kit by imatinib, lineage commitment depends upon inhibition of other PTKs. Thus, imatinib mimics “emergency hematopoiesis,” a physiological innate immune response to infection. Increasing neutrophil numbers by adoptive transfer sufficed to reduce mycobacterial load, and imatinib reduced bacterial load of Franciscella spp., which do not utilize imatinib-sensitive PTKs for pathogenesis. Thus, potentiation of the immune response by imatinib at low doses may facilitate clearance of diverse microbial pathogens. Host-directed therapeutics (HDTs) for infectious diseases target cellular mechanisms used by pathogens to move into, through, or out of cells. The Abl tyrosine kinase (TK) inhibitor and cancer therapeutic imatinib mesylate (Gleevec), for example, has activity against bacterial and viral pathogens via effects on pathogen entry (polyomaviruses), intracellular transit (Mycobacteria) and exit (poxviruses and filoviruses). Other HDTs target the host immune system by suppressing or activating circulating innate and adaptive cells. Here we report that imatinib at doses that are effective in clearing Mycobacterial infections but which are 10-fold lower than those used for cancer, mimics a physiological innate response to infection in the bone marrow, called the “emergency response,” in which hematopoietic stem cells and multipotent progenitors expand and differentiate into mature myeloid cells that migrate to peripheral sites. Imatinib effects occur in part via partial inhibition of c-Kit, suggesting a mechanism by which c-Kit controls the earliest stages of hematopoiesis. Mimicking a physiological antimicrobial response may make imatinib broadly useful. Accordingly, imatinib also has efficacy against infections caused by Franciscella spp., which do not use imatinib-sensitive TKs for pathogenesis. These observations identify myelopoiesis as an important target for HDTs, and provide information on how to dose imatinib for clinical use.
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Affiliation(s)
- Ruth J. Napier
- Microbiology and Molecular Genetics Graduate Program, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Brian A. Norris
- Immunology and Molecular Pathogenesis Graduate Program, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Alyson Swimm
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Cynthia R. Giver
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, United States of America
| | - Wayne A. C. Harris
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, United States of America
| | - Julie Laval
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Center for Cystic Fibrosis Research, Children’s Healthcare of Atlanta, Atlanta, Georgia, United States of America
- Institut de Génétique Moléculaire de Montpellier (IGMM), CNRS UMR5535, Université Montpellier, Montpellier, France
| | - Brooke A. Napier
- Microbiology and Molecular Genetics Graduate Program, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Gopi Patel
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Ryan Crump
- Department of Molecular Microbiology and Immunology, Saint Louis University, St. Louis, Missouri, United States of America
| | - Zhenghong Peng
- MD Anderson Cancer Center, University of Texas, Houston, Texas, United States of America
| | - William Bornmann
- MD Anderson Cancer Center, University of Texas, Houston, Texas, United States of America
| | - Bali Pulendran
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Emory Vaccine Center, Emory University, Atlanta, Georgia, United States of America
- Yerkes National Primate Research Center, Atlanta, Georgia, United States of America
| | - R. Mark Buller
- Department of Molecular Microbiology and Immunology, Saint Louis University, St. Louis, Missouri, United States of America
| | - David S. Weiss
- Emory Vaccine Center, Emory University, Atlanta, Georgia, United States of America
- Yerkes National Primate Research Center, Atlanta, Georgia, United States of America
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Rabindra Tirouvanziam
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Center for Cystic Fibrosis Research, Children’s Healthcare of Atlanta, Atlanta, Georgia, United States of America
| | - Edmund K. Waller
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, United States of America
| | - Daniel Kalman
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
- * E-mail:
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Schulze-Bonhage A, Hintz M. Perampanel in the management of partial-onset seizures: a review of safety, efficacy, and patient acceptability. Patient Prefer Adherence 2015; 9:1143-51. [PMID: 26316718 PMCID: PMC4542413 DOI: 10.2147/ppa.s63951] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Perampanel (PER) is a novel antiepileptic drug recently introduced for the adjunctive treatment in epilepsy patients aged 12 years or older with partial-onset seizures with or without secondary generalization in the US and Europe. Its antiepileptic action is based on noncompetitive inhibition of postsynaptic AMPA receptors, decreasing excitatory synaptic transmission. Evaluation of efficacy in three placebo-controlled randomized Phase III studies showed that add-on therapy of PER decreased seizure frequencies significantly compared to placebo at daily doses between 4 mg/day and 12 mg/day. PER's long half-life of 105 hours allows for once-daily dosing that is favorable for patient compliance with intake. Long-term extension studies showed a 62.5%-69.6% adherence of patients after 1 year of treatment, comparing favorably with other second-generation antiepileptic drugs. Whereas these trials demonstrated an overall favorable tolerability profile of PER, nonspecific central nervous system adverse effects like somnolence, dizziness, headache, and fatigue may occur. In addition, neuropsychiatric disturbances ranging from irritability to suicidality were reported in several case reports; both placebo-controlled and prospective long-term extension trials showed a low incidence of such behavioral and psychiatric complaints. For early recognition of neuropsychiatric symptoms like depression, anxiety, and aggression, slow titration and close monitoring during drug introduction are mandatory. This allows on the one hand to recognize patients particularly susceptible to adverse effects of the drug, and on the other hand to render the drug's full potential of seizure control available for the vast majority of patient groups tolerating the drug well.
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Affiliation(s)
- Andreas Schulze-Bonhage
- Epilepsy Center, University Medical Center Freiburg, Freiburg, Germany
- Correspondence: Andreas Schulze-Bonhage, Epilepsy Center, University Medical Center Freiburg, Breisacher Strasse 64, D-79106 Freiburg, Germany, Tel +49 761 2705 4250, Fax +49 761 2705 0030, Email
| | - Mandy Hintz
- Epilepsy Center, University Medical Center Freiburg, Freiburg, Germany
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El Desoky ES. The AMPA receptor antagonist perampanel is a new hope in the treatment for epilepsy. Fundam Clin Pharmacol 2014; 28:473-80. [DOI: 10.1111/fcp.12081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 03/31/2014] [Accepted: 04/17/2014] [Indexed: 12/18/2022]
Affiliation(s)
- Ehab S. El Desoky
- Department of Pharmacology; Faculty of Medicine; Assiut University; 71515 Assiut Egypt
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Zaccara G, Giovannelli F, Bell GS, Sander JW. Network meta-analyses of antiepileptic drug efficacy and tolerability in drug-resistant focal epilepsies: a clinical perspective. Eur J Clin Pharmacol 2014; 70:647-54. [PMID: 24676410 DOI: 10.1007/s00228-014-1669-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Accepted: 03/09/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE Network meta-analysis (NMA) is a new technique that allows multiple treatment comparisons and provides estimates of effect sizes for all possible pair-wise comparisons. Several NMAs of antiepileptic drug (AED) efficacy and tolerability in individuals with refractory focal epilepsy, however, came to non-specific and, in some cases, divergent conclusions. We review some clinical factors that may be responsible for these inconsistent findings. RESULTS A major issue is the small number of individuals included in the meta-analyses with consequent wide confidence intervals and lack of ability to achieve significant results. Further issues are lack of robustness of the measured efficacy outcome-the responder ratio (the percentage of individuals with a >50 % improvement in seizure frequency); the selection of randomized studies (RCTs) included, i.e., the inclusion of studies with heterogeneous populations (children and adults); and inclusion of people treated with different doses of the experimental drug. Some methods of analysing data from RCTs, such as the last observation carried forward (LOCF) analysis, the choice of different phases of the study to compare to baseline, and the year in which the trial was conducted, selectively affect measurement of efficacy outcomes. Titration speed and other methodological aspects selectively affect tolerability. CONCLUSION Several factors restrict the analysis of clinically useful estimates of the comparative efficacy of AEDs, while analysis of tolerability may be easier to accomplish.
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Affiliation(s)
- Gaetano Zaccara
- Unit of Neurology, Department of Medicine, Florence Health Authority, Florence, Italy,
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Kramer LD, Satlin A, Krauss GL, French J, Perucca E, Ben-Menachem E, Kwan P, Shih JJ, Laurenza A, Yang H, Zhu J, Squillacote D. Perampanel for adjunctive treatment of partial-onset seizures: a pooled dose-response analysis of phase III studies. Epilepsia 2014; 55:423-31. [PMID: 24605793 DOI: 10.1111/epi.12527] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2013] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To better understand the relationship between efficacy and perampanel dose, integrated actual (last) dose data from three phase III trials and an extension study (blinded Conversion Period; open-label Maintenance Period) were analyzed. METHODS Seizure frequency data were analyzed in patients who were randomized to and completed the 13-week Maintenance Period of the phase III studies on perampanel 8 mg, and who received an actual (last) dose of 12 mg during (1) the extension 16-week blinded Conversion Period or (2) weeks 1-13 of the extension Maintenance Period. Due to a treatment-by-region interaction (p = 0.042), analyses excluded patients from the Latin America region (n = 162/1,480; 10.9% of the treated cohort). RESULTS Of 372 patients randomized to 8 mg in the phase III studies, 273 completed the Maintenance Period at 8 mg and 267 entered the extension study. In patients who then had an actual (last) dose of 12 mg during the extension blinded Conversion Period (n = 217), median percent change in seizure frequency per 28 days improved from -32.4% (8 mg, phase III Maintenance Period) to -44.2% (12 mg, extension blinded Conversion Period); 50% responder rates increased slightly from 37.3% to 42.9%. In patients who completed the phase III studies on 8 mg and had an actual (last) dose of 12 mg during weeks 1-13 of the extension Maintenance Period (n = 181), median percent change in seizure frequency per 28 days improved from -34.1% (phase III Maintenance Period) to -46.0% (weeks 1-13 extension Maintenance Period); 50% responder rates were 39.2% and 46.4%. Seizure control remained substantially unchanged in patients who completed the phase III studies at 12 mg and continued on that dose during the extension. SIGNIFICANCE Increasing perampanel dose from 8 to 12 mg can produce additional benefits in seizure control in at least some patients who tolerate the higher dose.
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Affiliation(s)
- Lynn D Kramer
- Eisai Neuroscience and General Medicine Product Creation Unit, Eisai Inc, Woodcliff Lake, New Jersey, U.S.A
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Hanada T. The discovery and development of perampanel for the treatment of epilepsy. Expert Opin Drug Discov 2014; 9:449-58. [DOI: 10.1517/17460441.2014.891580] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Faulkner MA. Perampanel: A new agent for adjunctive treatment of partial seizures. Am J Health Syst Pharm 2014; 71:191-8. [DOI: 10.2146/ajhp130203] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Michele A. Faulkner
- Department of Neurology, School of Medicine, Creighton University, Omaha, NE
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Abstract
Each month, subscribers to The Formulary Monograph Service receive 5 to 6 well-documented monographs on drugs that are newly released or are in late phase 3 trials. The monographs are targeted to Pharmacy & Therapeutics Committees. Subscribers also receive monthly 1-page summary monographs on agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation/medication use evaluation (DUE/MUE) is also provided each month. With a subscription, the monographs are sent in print and are also available on-line. Monographs can be customized to meet the needs of a facility. A drug class review is now published monthly with The Formulary Monograph Service. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service.Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service, call The Formulary at 800-322-4349. The April 2013 monograph topics are alogliptin, crofelemer, lomitapide, ponatinib, and sumatriptan iontophoretic transdermal. The DUE/MUE is on alogliptin.
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Affiliation(s)
| | - Terri L Levien
- Clinical Associate Professor of Pharmacotherapy, Drug Information Center, Washington State University, Spokane, Washington
| | - Danial E Baker
- Director, Drug Information Center, and Professor of Pharmacy Practice, College of Pharmacy, Washington State University Spokane, PO Box 1495, Spokane, Washington 99210-1495. The authors indicate no relationships that could be perceived as a conflict of interest
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Shvarts V, Chung S. Perampanel: newly approved, novel antiepileptic medication for partial-onset seizures. Expert Rev Neurother 2014; 13:131-4. [DOI: 10.1586/ern.12.154] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Zaccara G, Giovannelli F, Cincotta M, Iudice A. AMPA receptor inhibitors for the treatment of epilepsy: the role of perampanel. Expert Rev Neurother 2014; 13:647-55. [PMID: 23739002 DOI: 10.1586/ern.13.46] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors in the postsynaptic membrane are involved in fast excitatory signaling in the brain and their activation may lead to the firing of action potentials. Talampanel and perampanel were the first noncompetitive AMPA receptor antagonists to be tested as add-on drugs in patients with refractory partial seizures, and were found to be effective in improving seizure control. Due to an unfavorable kinetic and tolerability profile, talampanel clinical development in the field of epilepsy was discontinued early while perampanel has been recently approved in Europe and the USA as adjunctive therapy for adults with partial seizures with or without secondary generalization. The recommended perampanel starting dose is 2 mg/day once daily, which can be increased up to the recommended maintenance dose of 4-8 mg/day. Increments should be of 2 mg/day and based on clinical response and tolerability. Titration should be performed at 1-week intervals or at lower speed and a 12-mg daily dose should be considered after careful evaluation. To date, no serious and/or idiosyncratic adverse effects have been associated with this agent. Most frequently reported adverse effects are dizziness, ataxia, aggression, irritability, vertigo, somnolence, fatigue, headache and gait disturbance. Weight increase is the only non-neurological adverse effects associated with perampanel.
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Affiliation(s)
- Gaetano Zaccara
- Unit of Neurology, Department of Medicine, Florence Health Authority, Firenze, Italy.
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Abstract
Perampanel is a selective, noncompetitive AMPA receptor antagonist that has recently been approved for treating localization-related epilepsy. This article reviews the pharmacology, clinical development, efficacy, and safety/tolerability of perampanel.
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47
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Kerling F, Kasper B. Efficacy of perampanel: a review of clinical trial data. Acta Neurol Scand 2013:25-9. [PMID: 23480153 DOI: 10.1111/ane.12101] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2013] [Indexed: 12/11/2022]
Abstract
The efficacy of adjunctive perampanel has been investigated in an extensive clinical development program across a broad, multinational population of patients with refractory partial-onset seizures. Further to the results of two Phase II dose-finding studies, perampanel was evaluated in three large Phase III registration studies at the predicted no-effect dose of 2 mg/day and the predicted effective doses of 4, 8, and 12 mg/day. In all three studies, perampanel 4, 8, and 12 mg/day consistently provided significant reductions in the frequency of partial-onset seizures compared with placebo. Improvements in responder rates and seizure freedom rates were also observed. In addition, data from recent interim analyses of extension studies have indicated that these efficacy outcomes may be maintained with long-term treatment. Overall, these studies form a solid evidence base to support the efficacy of adjunctive perampanel in the treatment of refractory partial-onset seizures.
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Affiliation(s)
- F. Kerling
- Department of Neurology; University of Ulm; Ulm; Germany
| | - B.S. Kasper
- Department of Neurology; Epilepsy Center; University of Erlangen; Erlangen; Germany
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Abstract
Introduction Current pathways for treatment of partial onset epilepsy are diverse and include 14 new antiepileptic drugs (AEDs) licensed for use as either monotherapy or adjunctive therapy. However, the impact of these new AEDs on the treatment of partial epilepsy has so far been disappointing and there persists a need for additional drugs. Recently, perampanel, a first-in-class AED was licensed as an adjunct for the management of refractory partial onset seizures with or without secondary generalization in patients 12 years and older. This review highlights the current management of partial epilepsy and analyses the published clinical and preclinical data of perampanel to consider its potential role in the treatment of partial epilepsy. Methods A literature review of Embase, Medline and PubMed was conducted in April 2013 using the search terms ‘perampanel’ and ‘AMPA receptor antagonist/blocker’. Publications were included if they discussed perampanel in the context of preclinical or clinical epilepsy. Results Perampanel acts on the glutamate pathway. It is a novel highly selective non-competitive alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor antagonist. This is a previously untargeted post-synaptic glutamate receptor. It is responsible for mediating rapid trans-synaptic signal transduction and hence believed to play a major role in seizure propagation. The three pivotal placebo-controlled trials of adjunctive perampanel demonstrated that the effective dosing range is 4–12 mg/day. The drug can be prescribed once daily, and its adverse effect profile is minimal with dizziness, fatigue, headache, and somnolence being the most commonly reported. Conclusions Perampanel is a welcome addition as it represents an alternative approach in the management of epilepsy with potential to have a significant impact on the prognosis of intractable epilepsy. However, it has only recently been licensed for clinical use in Europe, the USA, and Canada, and there are no data directly comparing it with other AEDs; hence, it remains far too early to ascertain its place in the treatment of patients with partial epilepsy.
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Epilepsy, antiseizure therapy, and sleep cycle parameters. EPILEPSY RESEARCH AND TREATMENT 2013; 2013:670682. [PMID: 23997949 PMCID: PMC3749600 DOI: 10.1155/2013/670682] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 07/04/2013] [Accepted: 07/18/2013] [Indexed: 01/16/2023]
Abstract
A reciprocal relationship exists between sleep and epilepsy. The quality of sleep is affected by the presence and frequency of seizures, type of antiepileptic therapy utilized, and coexisting primary sleep disorders. Daytime somnolence is one of the most common adverse effects of antiepileptic therapy, with specific pharmacologic agents exhibiting a unique influence on components of sleep architecture. The newer generation of antiseizure drugs demonstrates improved sleep efficiency, greater stabilization of sleep architecture, prolongation of REM sleep duration, and increased quality of life measures. The emerging field of chronoepileptology explores the relationship between seizures and circadian rhythms, aiming for targeted use of antiseizure therapies to maximize therapeutic effects and minimize the adverse events experienced by the patients.
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Faulkner MA, Burke RA. Safety profile of two novel antiepileptic agents approved for the treatment of refractory partial seizures: ezogabine (retigabine) and perampanel. Expert Opin Drug Saf 2013; 12:847-55. [DOI: 10.1517/14740338.2013.823399] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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