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Treadwell JR, Kessler SK, Wu M, Abend NS, Massey SL, Tsou AY. Pharmacologic and Dietary Treatments for Epilepsies in Children Aged 1-36 Months: A Systematic Review. Neurology 2023; 100:e16-e27. [PMID: 36270899 PMCID: PMC9827128 DOI: 10.1212/wnl.0000000000201026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 06/13/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Early life epilepsies are common and often debilitating, but no evidence-based management guidelines exist outside of those for infantile spasms. We conducted a systematic review of the effectiveness and harms of pharmacologic and dietary treatments for epilepsy in children aged 1-36 months without infantile spasms. METHODS We searched EMBASE, MEDLINE, PubMed, and the Cochrane Library for studies published from January 1, 1999, to August 19, 2021. Using prespecified criteria, we identified studies reporting data on children aged 1-36 months receiving pharmacologic or dietary treatments for epilepsy. We did not require that studies report etiology-specific data. We excluded studies of neonates, infantile spasms, and status epilepticus. We included studies administering 1 of 29 pharmacologic treatments and/or 1 of 5 dietary treatments reporting effectiveness outcomes at ≥ 12 weeks. We reviewed the full text to find any subgroup analyses of children aged 1-36 months. RESULTS Twenty-three studies met inclusion criteria (6 randomized studies, 2 nonrandomized comparative studies, and 15 prestudies/poststudies). All conclusions were rated low strength of evidence. Levetiracetam leads to seizure freedom in some infants (32% and 66% in studies reporting seizure freedom), but data on 6 other medications were insufficient to permit conclusions about effectiveness (topiramate, lamotrigine, phenytoin, vigabatrin, rufinamide, and stiripentol). Three medications (levetiracetam, topiramate, and lamotrigine) were rarely discontinued because of adverse effects, and severe events were rare. For diets, the ketogenic diet leads to seizure freedom in some infants (rates 12%-37%), and both the ketogenic diet and modified Atkins diet reduce average seizure frequency, but reductions are greater with the ketogenic diet (1 RCT reported a 71% frequency reduction at 6 months for ketogenic diet vs only a 28% reduction for the modified Atkins diet). Dietary harms were not well-reported. DISCUSSION Little high-quality evidence exists on pharmacologic and dietary treatments for early life epilepsies. Future research should isolate how treatments contribute to outcomes, conduct etiology-specific analyses, and report patient-centered outcomes such as hospitalization, neurodevelopment, functional performance, sleep quality, and patient and caregiver quality of life. TRIAL REGISTRATION INFORMATION This systematic review was registered in PROSPERO (CRD42021220352) on March 5, 2021.
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Affiliation(s)
- Jonathan R Treadwell
- From the ECRI-Penn Medicine Evidence-based Practice Center (J.R.T., M.W., A.Y.T.), ECRI, Plymouth Meeting, PA; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Biostatistics, Epidemiology and Informatics (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Division of Neurology (A.Y.T.), Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA.
| | - Sudha Kilaru Kessler
- From the ECRI-Penn Medicine Evidence-based Practice Center (J.R.T., M.W., A.Y.T.), ECRI, Plymouth Meeting, PA; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Biostatistics, Epidemiology and Informatics (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Division of Neurology (A.Y.T.), Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA
| | - Mingche Wu
- From the ECRI-Penn Medicine Evidence-based Practice Center (J.R.T., M.W., A.Y.T.), ECRI, Plymouth Meeting, PA; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Biostatistics, Epidemiology and Informatics (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Division of Neurology (A.Y.T.), Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA
| | - Nicholas S Abend
- From the ECRI-Penn Medicine Evidence-based Practice Center (J.R.T., M.W., A.Y.T.), ECRI, Plymouth Meeting, PA; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Biostatistics, Epidemiology and Informatics (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Division of Neurology (A.Y.T.), Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA
| | - Shavonne L Massey
- From the ECRI-Penn Medicine Evidence-based Practice Center (J.R.T., M.W., A.Y.T.), ECRI, Plymouth Meeting, PA; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Biostatistics, Epidemiology and Informatics (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Division of Neurology (A.Y.T.), Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA
| | - Amy Y Tsou
- From the ECRI-Penn Medicine Evidence-based Practice Center (J.R.T., M.W., A.Y.T.), ECRI, Plymouth Meeting, PA; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Biostatistics, Epidemiology and Informatics (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Division of Neurology (A.Y.T.), Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA
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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: 150] [Impact Index Per Article: 21.4] [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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