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Korinthenberg R, Bast T, Haberlandt E, Stephani U, Strzelczyk A, Rücker G. Efficacy and safety of corticosteroids and ACTH in epileptic syndromes beyond Infantile Epileptic Spasms Syndrome (IESS): A systematic review and meta-analysis. Epilepsia 2024; 65:1155-1175. [PMID: 38411568 DOI: 10.1111/epi.17918] [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: 12/06/2023] [Revised: 02/02/2024] [Accepted: 02/02/2024] [Indexed: 02/28/2024]
Abstract
We conducted a systematic review investigating the efficacy and tolerability of adrenocorticotropic hormone (ACTH) and corticosteroids in children with epilepsies other than infantile epileptic spasm syndrome (IESS) that are resistant to anti-seizure medication (ASM). We included retrospective and prospective studies reporting on more than five patients and with clear case definitions and descriptions of treatment and outcome measures. We searched multiple databases and registries, and we assessed the risk of bias in the selected studies using a questionnaire based on published templates. Results were summarized with meta-analyses that pooled logit-transformed proportions or rates. Subgroup analyses and univariable and multivariable meta-regressions were performed to examine the influence of covariates. We included 38 studies (2 controlled and 5 uncontrolled prospective; 31 retrospective) involving 1152 patients. Meta-analysis of aggregate data for the primary outcomes of seizure response and reduction of electroencephalography (EEG) spikes at the end of treatment yielded pooled proportions (PPs) of 0.60 (95% confidence interval [CI] 0.52-0.67) and 0.56 (95% CI 0.43-0.68). The relapse rate was high (PP 0.33, 95% CI 0.27-0.40). Group analyses and meta-regression showed a small benefit of ACTH and no difference between all other corticosteroids, a slightly better effect in electric status epilepticus in slow sleep (ESES) and a weaker effect in patients with cognitive impairment and "symptomatic" etiology. Obesity and Cushing's syndrome were the most common adverse effects, occurring more frequently in trials addressing continuous ACTH (PP 0.73, 95% CI 0.48-0.89) or corticosteroids (PP 0.72, 95% CI 0.54-0.85) than intermittent intravenous or oral corticosteroid administration (PP 0.05, 95% CI 0.02-0.10). The validity of these results is limited by the high risk of bias in most included studies and large heterogeneity among study results. This report was registered under International Prospective Register of Systematic Reviews (PROSPERO) number CRD42022313846. We received no financial support.
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Affiliation(s)
- Rudolf Korinthenberg
- Division of Neuropediatrics and Muscular Disorders, Faculty of Medicine, University Medical Center (UMC), University of Freiburg, Freiburg, Germany
| | | | - Edda Haberlandt
- Department of Pediatrics and Adolescent Medicine, Dornbirn Hospital, Dornbirn, Austria
| | - Ulrich Stephani
- Clinic for Children and Adolescents II (Neuropediatrics, Social Pediatrics), University Hospital Schleswig Holstein (UKSH), Kiel, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe University and University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Gerta Rücker
- Medical Faculty and Medical Center, Institute for Medical Biometry and Statistics, University of Freiburg, Freiburg, Germany
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Kapoor D, Sharma S, Garg D, Samaddar S, Panda I, Patra B, Mukherjee SB, Pemde HK. Intravenous Methylprednisolone Versus Oral Prednisolone for West Syndrome: A Randomized Open-Label Trial. Indian J Pediatr 2021; 88:778-784. [PMID: 33575989 PMCID: PMC7877308 DOI: 10.1007/s12098-020-03630-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 12/16/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To compare intravenous methylprednisolone (IVMP) with oral prednisolone (OP) for the treatment of West syndrome. METHODS In this randomized, open-label trial, children aged 2 to 30 mo presenting with epileptic spasms with hypsarrhythmia or its variants on EEG were randomized to receive either IVMP (30 mg/kg/d for 3 d followed by oral prednisolone taper) or OP (4 mg/kg/d for two weeks followed by taper). The primary outcome measure was spasms cessation on day 14. Secondary outcomes included time to response, electroclinical remission at 2 and 6 wk, and frequency of adverse effects. ( ClinicalTrials.gov Identifier: NCT03876444). RESULTS Sixty children were enrolled; 31 in the IVMP and 29 in the OP arm. Proportion of children achieving spasms cessation at day 14 was similar in both groups (54.8% versus 68.9%, p = 0.26). Time to achieve remission was lower in the IVMP group (mean 5.4 ± 0.9 versus 9.5 ± 2.6 d, p < 0.0001). Electroclinical remission at 2 wk was similar in both groups (51.6% versus 44.8%, p = 0.59) but lower at 6 wk in the IVMP group (45.2% versus 75.9%, p < 0.015). Adverse effects like sleep disturbance, irritability and hypertension were more common in IVMP group whereas weight gain was more common in the OP group. CONCLUSIONS There was no significant difference in spasms cessation between the groups on day 14 although remission was higher at 6 wk in OP group. Our study suggests that OP was better than IVMP in efficacy and sustained remission with fewer adverse effects.
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Affiliation(s)
- Dipti Kapoor
- Division of Neurology, Department of Pediatrics, Kalawati Saran Children's Hospital and Lady Hardinge Medical College, New Delhi, 110001, India
| | - Suvasini Sharma
- Division of Neurology, Department of Pediatrics, Kalawati Saran Children's Hospital and Lady Hardinge Medical College, New Delhi, 110001, India.
| | - Divyani Garg
- Department of Neurology, Smt. Sucheta Kriplani Hospital and Lady Hardinge Medical College, New Delhi, India
| | - Sukla Samaddar
- Division of Neurology, Department of Pediatrics, Kalawati Saran Children's Hospital and Lady Hardinge Medical College, New Delhi, 110001, India
| | - Isha Panda
- Division of Neurology, Department of Pediatrics, Kalawati Saran Children's Hospital and Lady Hardinge Medical College, New Delhi, 110001, India
| | - Bijoy Patra
- Division of Neurology, Department of Pediatrics, Kalawati Saran Children's Hospital and Lady Hardinge Medical College, New Delhi, 110001, India
| | - Sharmila B Mukherjee
- Division of Neurology, Department of Pediatrics, Kalawati Saran Children's Hospital and Lady Hardinge Medical College, New Delhi, 110001, India
| | - Harish K Pemde
- Division of Neurology, Department of Pediatrics, Kalawati Saran Children's Hospital and Lady Hardinge Medical College, New Delhi, 110001, India
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Chatterjee A, Mundlamuri RC, Kenchaiah R, Asranna A, Nagappa M, Bindu PS, Seshagiri DV, Viswanathan LG, Shreedhar AS, Duble S, Rangarajan A, Khilari M, Bharath RD, Saini J, Thennarasu K, Taly AB, Sinha S. Role of pulse methylprednisolone in epileptic encephalopathy: A retrospective observational analysis. Epilepsy Res 2021; 173:106611. [PMID: 33740698 DOI: 10.1016/j.eplepsyres.2021.106611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/02/2021] [Accepted: 03/09/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To study the effect of monthly pulses of intravenous methylprednisolone (IVMP) on seizure and global outcomes in children with epileptic encephalopathy (EE). METHODS This retrospective study was undertaken in a tertiary care epilepsy center in India. Consecutive patients with EE who had received IVMP as adjunctive therapy for a minimum of 3 months and had at least one pre-and post-steroid EEG each, were identified and a structured questionnaire was used to collect information including outcomes at 3 months post-steroid course completion and beyond, as available. RESULTS Ninety-seven patients (M:F=71:26) fulfilling the inclusion criteria with a mean age at onset of seizures being 20.52 ± 25.69 months were included. Commonest seizure types were myoclonic (66%); Lennaux-Gastaut and West Syndromes accounted for 57 % and 24 % patients respectively. The etiology was unknown in 52 %. All children were on a combination of standard anti-seizure drugs. The duration of IVMP pulse therapy was 7.72 ± 6.25 months. One-fourth (26 %) patients experienced minor adverse events. Greater than 50 % seizure burden reduction was seen in 66 % patients at 3 months with seizure-freedom in 25 %. A total of 45 (46 %) patients became seizure-free in the cohort eventually with continuation of steroids beyond 3 months. Children with idiopathic EEs, normal neuroimaging, myoclonic jerks, and West syndrome showed the best response. The presence of burst-suppression and generalized paroxysmal fast activity (GPFA) predicted inadequate response. CONCLUSIONS Adjunct pulse doses of IVMP are safe, well-tolerated, and effective in reducing seizures and improving global outcomes in children with idiopathic EEs, West syndrome, normal neuroimaging, and myoclonic jerks. Seizure freedom might be delayed in a subset of these patients, hence duration of therapy beyond 3 months may be warranted.
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Affiliation(s)
- Aparajita Chatterjee
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India
| | | | - Raghavendra Kenchaiah
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India
| | - Ajay Asranna
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India
| | - M Nagappa
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India
| | - P S Bindu
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India
| | - D V Seshagiri
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India
| | | | - A S Shreedhar
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India
| | - Sisir Duble
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India
| | - Anush Rangarajan
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India
| | - Madhuri Khilari
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India
| | - Rose Dawn Bharath
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India
| | - Jitender Saini
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India
| | - K Thennarasu
- Department of Biostatistics, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India
| | - Arun B Taly
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India
| | - Sanjib Sinha
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, 560011, India.
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Pera MC, Randazzo G, Masnada S, Dontin SD, De Giorgis V, Balottin U, Veggiotti P. Intravenous methylprednisolone pulse therapy for children with epileptic encephalopathy. FUNCTIONAL NEUROLOGY 2016; 30:173-9. [PMID: 26910177 DOI: 10.11138/fneur/2015.30.3.173] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The aim of this retrospective study of children affected by epileptic encephalopathy was to evaluate seizure frequency, electroencephalographic pattern and neuropsychological status, before and after intravenous methylprednisolone therapy. Eleven children with epileptic encephalopathy were administered one cycle of intravenous methylprednisolone (15-30 mg/kg/day for three consecutive days, once a month for four months) in addition to constant dosages of their regular antiepileptic drugs. The treatment resulted in statistically significant reductions of generalized slow spike-and-wave discharges (p<0.0028) and seizure frequency (p<0.013), which persisted even after methylprednisolone pulse therapy was stopped. A globally positive outcome was noted in 9/11 patients (81.8%). This methylprednisolone treatment regimen did not cause significant or persistent adverse effects. We suggest that children with epileptic encephalopathy without an underlying structural lesion could be the best candidates for intravenous methylprednisolone pulse therapy.
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Almaabdi KH, Alshehri RO, Althubiti AA, Alsharef ZH, Mulla SN, Alshaer DS, Alfaidi NS, Jan MM. Intravenous methylprednisolone for intractable childhood epilepsy. Pediatr Neurol 2014; 50:334-6. [PMID: 24507698 DOI: 10.1016/j.pediatrneurol.2013.12.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 12/11/2013] [Accepted: 12/12/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Steroids have been used for the treatment of certain epilepsy types, such as infantile spasms; however, the use in the treatment of other intractable epilepsies has received limited study. We report our experience with intravenous methylprednisolone in children with epilepsy refractory to multiple antiepileptic drugs. METHODS A series of consecutive children were analyzed retrospectively. Patients with infantile spasms, progressive degenerative, or metabolic disorders were excluded. RESULTS Seventeen children aged 2-14 (mean 5.3) years were included. Associated cognitive and motor deficits were recognized in 82%. Most children (88%) had daily seizures and 13 (76%) were admitted previously with status epilepticus. The epilepsy was cryptogenic (unknown etiology) in 47% and the seizures were mixed in 41%. Intravenous methylprednisolone was given at 15 mg/kg per day followed by a weaning dose of oral prednisolone for 2-8 weeks (mean 3 weeks). Children were followed for 6-24 months (mean 18). Six (35%) children became completely seizure free; however, three of them later developed recurrent seizures. At 6 months posttreatment, improved seizure control was noted in 10 (59%) children. Children with mixed seizures were more likely to have a favorable response than those with one seizure type (49% vs 31%, P = 0.02). No major side effects were noted, and 35% of the parents reported improvements in their child's alertness and appetite. CONCLUSION Add-on steroid treatment for children with intractable epilepsy is safe and may be effective in some children when used in a short course.
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Affiliation(s)
- Kholoud H Almaabdi
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Rawan O Alshehri
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Areej A Althubiti
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Zainab H Alsharef
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Sara N Mulla
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Dareen S Alshaer
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Nouf S Alfaidi
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohammed M Jan
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.
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