Preliminary study on the efficacy and tolerability of newer anticonvulsants in a population of epileptic patients

Development of outcome criteria to measure effectiveness of antiepileptic therapy in children

PURPOSE

Clinical trials of antiepileptic drugs frequently measure outcomes of seizure control, which demonstrate efficacy. Yet, functional status, quality of life, and long-term treatment effects reflecting effectiveness are scarcely assessed. We sought to use a consensus method to help identify which outcome criteria key stakeholders consider should be used to measure effectiveness in trials of antiepileptic treatments for children.

METHOD

A two-round Delphi survey was used; parents of children with epilepsy and local, international experts comprising academics and clinicians participated in the survey. In the first round, 32 experts, 50 parents, and 15 children with epilepsy aged >13years suggested outcomes that they considered important in determining effectiveness of antiepileptic therapy in children, separately for preschool and school age. In the second round, 29 experts and 42 parents scored the importance of outcomes from the list suggested by at least 10% of round 1 respondents and also proposed five most important outcomes.

RESULTS

Complete seizure freedom (67%), seizure frequency (48%), ability to perform normal day-to-day activities (45%), and quality of life (40%) were identified as the most important outcomes of antiepileptic therapy in children of both age groups. Additionally, effect on developmental milestones (47%) and child's compliance to treatment regimen (39%) were identified as most important in preschool age group and school performance (49%); adverse effects (39%) were identified as most important in school age group.

CONCLUSION

For the first time, this study has identified outcome priorities regarding antiepileptic treatment in children based on the key stakeholders' perspectives. It could be used as a provisional list of outcomes for inclusion in a core outcome set for children with epilepsy.

New generation antiepileptic drugs: what do they offer in terms of improved tolerability and safety?

Over the last two decades a total of 11 antiepileptic drugs (AEDs) have been introduced to the US market. Randomized, placebo-controlled trials have yielded information about each drug's efficacy, tolerability, and safety profile; however, few studies have compared the newer generation AEDs directly with the older generation. Comparative studies are not always straightforward in their interpretation, as many characteristics of drugs, both favorable and unfavorable, may not be highlighted by such studies. In general, findings from the literature suggest that the newer generation AEDs (including vigabatrin, felbamate, gabapentin, lamotrigine, tiagabine, topiramate, levetiracetam, oxcarbazepine, zonisamide, pregabalin, rufinamide, and lacosamide) enjoy both improved tolerability and safety compared with older agents such as phenobarbital, phenytoin, carbamazepine, and valproate. This is partially supported by some of the findings of the QSS and the TTA Committee of the American Academy of Neurology (AAN), whose review of four AEDs (gabapentin, lamotrigine, topiramate, and tiagabine) is discussed. Briefly, when compared with carbamazepine, lamotrigine was better tolerated; topiramate adverse events (AEs) were fairly comparable to carbamazepine and valproate; and tiagabine compared with placebo was associated with a higher discontinuation rate due to AEs. The findings of the SANAD trial are also presented; when administered to patients with partial epilepsy, carbamazepine was most likely to fail due to AEs, and lamotrigine and gabapentin were least likely to fail due to AEs. When administered to patients with idiopathic generalized epilepsy, topiramate was most frequently associated with AE-related discontinuation, followed by valproate; and while valproate was the most efficacious drug in this arm of the study, lamotrigine was more tolerable. What makes the SANAD study valuable and somewhat unique is its head-to-head comparison of one drug with another. Such comparative trials are overall lacking for new AEDs, although some conclusions can be drawn from the available data. In the end, however, AED selection must be based on individual patient and drug characteristics.

New treatment option for partial-onset seizures: efficacy and safety of lacosamide

More than 30% of epilepsy patients remain refractory despite the advent of new antiepileptic drugs (AEDs) over two decades. Although a small percentage of these refractory patients may become seizure free when a new AED is added, combined administration of AEDs or the application of novel AEDs is the most common therapeutic option when surgical treatment cannot be offered. The most recently approved AED in Europe and the USA is lacosamide (LCM), which offers new mechanisms of action and favorable safety profiles. This article reviews LCM's molecular mechanisms of action, pharmacokinetic profiles as well as efficacy and safety from phase II and III clinical trials. In addition, comparison between LCM and other existing AEDs is discussed.

Strategies to detect adverse effects of antiepileptic drugs in clinical practice

OBJECTIVE

The aim was to study the frequency and types of adverse effects (AEs) in patients treated with antiepileptic drugs (AEDs) according to the strategies used by the neurologist to detect them.

METHOD

This cross-sectional epidemiological study was carried out in standard clinical practice. Two strategies were used to detect AEs: spontaneous reporting by the patient, and a checklist of possible treatment-related adverse reactions completed by the patient.

RESULTS

A total of 579 patients were recruited for the study. Roughly a third (33.7%) reported AEs spontaneously, and 65.2% did so when administered the checklist. The main reason for changing medication was lack of efficacy, but significant side effects were also an important reason for modifying treatment in those patients who reported higher levels of discomfort.

CONCLUSIONS

The use of an active approach is recommended for detection of AEs of AED treatment. AEs appear to have a key effect on the decision to change treatment.

Treating elderly people with diabetes and stages 3 and 4 chronic kidney disease

Dedicated European and US clinical guidelines for type 2 diabetes in the elderly have been released, but they do not specifically address the issue of advanced chronic kidney disease (CKD) in older patients with diabetes. General clinical guidelines have been published on the treatment of patients with diabetic nephropathy (DN), but these address the issue of how to prevent progression and treat advanced DN without distinguishing between different age groups. Elderly patients with diabetes and stages 3 to 4 CKD have particular needs that differ from those of younger patients with the same conditions. This is mainly due to their frailty and shorter life expectancy. Differently tailored therapeutic strategies are needed, which may have less stringent targets; and the use of common drugs should be critically evaluated. The management agenda (metabolic control, low-protein diet, controlling BP, preventing progression of advanced DN, preventing cardiovascular outcomes) for these patients is discussed in light of the limits and perspectives of current guidelines. Intensive, simultaneous management of all items on the agenda may not be feasible for a proportion of older patients, and clinicians may have to give priority to reducing some risk factors rather than others, choosing between different therapies.

Comparative retention rates and long-term tolerability of new antiepileptic drugs

OBJECTIVE

Retention rates of five new anti-epileptic medications (AEDs) were compared in order to evaluate their long-term tolerability and efficacy.

METHOD

We acquired the retention data on levetiracetam (LEV), lamotrigine (LTG), oxcarbazepine (OXC), topiramate (TPM), and zonisamide (ZNS) from the electronic database. The data included patient's age, gender, seizure type, current and previous medications, dosage, main reasons for discontinuation, and duration of therapy. The retention rates of these AEDs were evaluated at 4, 12, 24, 52, and 104 weeks.

RESULTS

A total of 828 new AED exposures were obtained (LEV=196, LTG=251, OXC=97, TPM=156, ZNS=128) from patients with partial or generalized epilepsy. At 2 years, retention rate was highest with LTG (74.1%), followed by ZNS (60.2%), OXC (58.8%), LEV (53.6%), and TPM (44.2%). When these AEDs were discontinued, it was mainly due to inefficacy (29.5%) and sedating side-effects (20.5%), and commonly within 6 months into therapy. Several important AED specific side-effects leading to discontinuation were identified, including behavioral or irritability from LEV, rash from LTG and OXC, nausea from OXC and ZNS, hyponatremia from OXC, and kidney stones from TPM and ZNS.

CONCLUSION

Comparing retention rates of new AEDs can provide useful insight into their tolerability and efficacy. This study showed highest retention rate with LTG, which was significantly different from ZNS (p=0.0025), LEV (p<0.0001), OXC (p=0.0024), and TPM (p<0.0001). Beside ineffectiveness, other leading causes of discontinuation were adverse behavioral effects with LEV, rash with LTG and OXC, and sedation for TPM and ZNS.

Systolic hypertension in older persons: complexities in clinical decision making

While the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) challenges clinicians to aggressively manage systolic hypertension, few data are available to guide clinicians in treating older persons with this condition. In older persons, hypertension treatment decisions must often rely on extrapolations and fall into a gray area where optimal choice for an individual patient may be unclear. In these instances, patients must understand the probable outcomes of options, consider the personal value they place on benefits vs. risks, and participate with their practitioners in deciding on treatment. Shared decision making is the process by which the health care provider and patient share all stages of the decision-making process and both discuss treatment preferences and agree on a final management plan. Our challenge as clinicians is to ensure that all older patients have the opportunity to be treated in a way that is evidence-based and patient-centered. As with most health care decisions in older persons, those regarding blood pressure control should promote evidence-based care that is complementary with individualized risk, benefit ratios, patient preferences, and treatment goals.