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Kerr WT, Kok N, Reddy AS, McFarlane KN, Stern JM, Pennell PB, Stacey W, French J. Demonstration of Group-Level and Individual-Level Efficacy Using Time-to-Event Designs for Clinical Trials of Antiseizure Medications. Neurology 2024; 103:e209713. [PMID: 39052963 PMCID: PMC11271390 DOI: 10.1212/wnl.0000000000209713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 05/24/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Participants with treatment-resistant epilepsy who are randomized to add-on placebo and remain in a trial for the typical 3 to 5-month maintenance period may be at increased risk of adverse outcomes. A novel trial design has been suggested, time to prerandomization monthly seizure count (T-PSC), which would limit participants' time on ineffective therapy. We reanalyzed 11 completed trials to determine whether the primary efficacy conclusions at T-PSC matched each of the original, longer trials. METHODS A total of 11 double-blind, placebo-controlled trials of levetiracetam, brivaracetam, lacosamide, topiramate, and lamotrigine for either focal-onset or generalized-onset epilepsy were selected. We evaluated the group-level and individual-level efficacy of treatments including the median percent reduction (MPR) in seizure frequency and 50% responder rate (50RR) at T-PSC, time to second seizure, and time to first seizure compared with the full-length trial. RESULTS The primary efficacy conclusions of 10 of the 11 trials would have been the same with a T-PSC design compared with the traditional design (the exception of lamotrigine had a very high initial placebo response). As a proportion of the full-length effect size, 90% of the MPR and 85% of the 50RR were seen at T-PSC (95% CI 73%-113% and 65%-110%, respectively). Using the T-PSC design, the time on blinded treatment was at least 312 participant-years shorter (40% of total duration) and 142,000 seizures occurred during this time (60% of total seizures). By contrast, the time to first or second seizure designs reproduced group-level effect size, but the primary efficacy conclusions of each trial and individual-level efficacy correspondence were fair to poor. DISCUSSION These results support the use of this trial design for new epilepsy medication trials because this reanalysis of 11 randomized controlled trials demonstrated that observation until T-PSC was sufficient to demonstrate efficacy while potentially improving participant safety by reducing the time of exposure to placebo and inadequate treatment. Despite analysis of 11 trials including 3,619 participants, we did not observe a significant reduction in the group-level effect size, which is directly related to statistical power. The next step is to evaluate whether T-PSC is sufficient to evaluate safety as measured by adverse events.
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Affiliation(s)
- Wesley T Kerr
- From the Department of Neurology (W.T.K., N.K., A.S.R., K.N.M., P.B.P.), and Department of Biomedical Informatics (W.T.K.), University of Pittsburgh, PA; Department of Neurology (W.T.K., N.K., A.S.R., W.S.), University of Michigan, Ann Arbor; Department of Neurology (W.T.K., J.M.S.), University of California, Los Angeles; Department of Biomedical Engineering (W.S.), University of Michigan, Ann Arbor; and Comprehensive Epilepsy Center (J.F.), New York University Grossman School of Medicine, New York
| | - Neo Kok
- From the Department of Neurology (W.T.K., N.K., A.S.R., K.N.M., P.B.P.), and Department of Biomedical Informatics (W.T.K.), University of Pittsburgh, PA; Department of Neurology (W.T.K., N.K., A.S.R., W.S.), University of Michigan, Ann Arbor; Department of Neurology (W.T.K., J.M.S.), University of California, Los Angeles; Department of Biomedical Engineering (W.S.), University of Michigan, Ann Arbor; and Comprehensive Epilepsy Center (J.F.), New York University Grossman School of Medicine, New York
| | - Advith S Reddy
- From the Department of Neurology (W.T.K., N.K., A.S.R., K.N.M., P.B.P.), and Department of Biomedical Informatics (W.T.K.), University of Pittsburgh, PA; Department of Neurology (W.T.K., N.K., A.S.R., W.S.), University of Michigan, Ann Arbor; Department of Neurology (W.T.K., J.M.S.), University of California, Los Angeles; Department of Biomedical Engineering (W.S.), University of Michigan, Ann Arbor; and Comprehensive Epilepsy Center (J.F.), New York University Grossman School of Medicine, New York
| | - Katherine N McFarlane
- From the Department of Neurology (W.T.K., N.K., A.S.R., K.N.M., P.B.P.), and Department of Biomedical Informatics (W.T.K.), University of Pittsburgh, PA; Department of Neurology (W.T.K., N.K., A.S.R., W.S.), University of Michigan, Ann Arbor; Department of Neurology (W.T.K., J.M.S.), University of California, Los Angeles; Department of Biomedical Engineering (W.S.), University of Michigan, Ann Arbor; and Comprehensive Epilepsy Center (J.F.), New York University Grossman School of Medicine, New York
| | - John M Stern
- From the Department of Neurology (W.T.K., N.K., A.S.R., K.N.M., P.B.P.), and Department of Biomedical Informatics (W.T.K.), University of Pittsburgh, PA; Department of Neurology (W.T.K., N.K., A.S.R., W.S.), University of Michigan, Ann Arbor; Department of Neurology (W.T.K., J.M.S.), University of California, Los Angeles; Department of Biomedical Engineering (W.S.), University of Michigan, Ann Arbor; and Comprehensive Epilepsy Center (J.F.), New York University Grossman School of Medicine, New York
| | - Page B Pennell
- From the Department of Neurology (W.T.K., N.K., A.S.R., K.N.M., P.B.P.), and Department of Biomedical Informatics (W.T.K.), University of Pittsburgh, PA; Department of Neurology (W.T.K., N.K., A.S.R., W.S.), University of Michigan, Ann Arbor; Department of Neurology (W.T.K., J.M.S.), University of California, Los Angeles; Department of Biomedical Engineering (W.S.), University of Michigan, Ann Arbor; and Comprehensive Epilepsy Center (J.F.), New York University Grossman School of Medicine, New York
| | - William Stacey
- From the Department of Neurology (W.T.K., N.K., A.S.R., K.N.M., P.B.P.), and Department of Biomedical Informatics (W.T.K.), University of Pittsburgh, PA; Department of Neurology (W.T.K., N.K., A.S.R., W.S.), University of Michigan, Ann Arbor; Department of Neurology (W.T.K., J.M.S.), University of California, Los Angeles; Department of Biomedical Engineering (W.S.), University of Michigan, Ann Arbor; and Comprehensive Epilepsy Center (J.F.), New York University Grossman School of Medicine, New York
| | - Jacqueline French
- From the Department of Neurology (W.T.K., N.K., A.S.R., K.N.M., P.B.P.), and Department of Biomedical Informatics (W.T.K.), University of Pittsburgh, PA; Department of Neurology (W.T.K., N.K., A.S.R., W.S.), University of Michigan, Ann Arbor; Department of Neurology (W.T.K., J.M.S.), University of California, Los Angeles; Department of Biomedical Engineering (W.S.), University of Michigan, Ann Arbor; and Comprehensive Epilepsy Center (J.F.), New York University Grossman School of Medicine, New York
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Kerr WT, McFarlane KN, Figueiredo Pucci G. The present and future of seizure detection, prediction, and forecasting with machine learning, including the future impact on clinical trials. Front Neurol 2024; 15:1425490. [PMID: 39055320 PMCID: PMC11269262 DOI: 10.3389/fneur.2024.1425490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 06/03/2024] [Indexed: 07/27/2024] Open
Abstract
Seizures have a profound impact on quality of life and mortality, in part because they can be challenging both to detect and forecast. Seizure detection relies upon accurately differentiating transient neurological symptoms caused by abnormal epileptiform activity from similar symptoms with different causes. Seizure forecasting aims to identify when a person has a high or low likelihood of seizure, which is related to seizure prediction. Machine learning and artificial intelligence are data-driven techniques integrated with neurodiagnostic monitoring technologies that attempt to accomplish both of those tasks. In this narrative review, we describe both the existing software and hardware approaches for seizure detection and forecasting, as well as the concepts for how to evaluate the performance of new technologies for future application in clinical practice. These technologies include long-term monitoring both with and without electroencephalography (EEG) that report very high sensitivity as well as reduced false positive detections. In addition, we describe the implications of seizure detection and forecasting upon the evaluation of novel treatments for seizures within clinical trials. Based on these existing data, long-term seizure detection and forecasting with machine learning and artificial intelligence could fundamentally change the clinical care of people with seizures, but there are multiple validation steps necessary to rigorously demonstrate their benefits and costs, relative to the current standard.
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Affiliation(s)
- Wesley T. Kerr
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, United States
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Falip M, López González FJ, Martín-Herranz I, Merino-Bohórquez V, Montoya J, Rey Gómez-Serranillos I, Rodriguez Uranga JJ, Ruiz E, Sancho-López A, Trillo Mata JL, Antoni Vallès J, Álvarez-Barón E, Sabaniego J, Subías-Labazuy S, Gil A. Value contribution of cenobamate for the treatment of Focal-Onset Seizures (FOS) in patients with drug-resistant epilepsy (DRE) in Spain through reflective Multi-Criteria Decision Analysis (MCDA). Epilepsy Behav 2023; 145:109350. [PMID: 37480633 DOI: 10.1016/j.yebeh.2023.109350] [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: 04/27/2023] [Revised: 06/27/2023] [Accepted: 06/29/2023] [Indexed: 07/24/2023]
Abstract
INTRODUCTION Epilepsy is one of the most common neurological conditions worldwide. The main goal of its treatment is to achieve seizure freedom without intolerable adverse effects. However, despite the availability of many anti-seizure medications, including the latest options, called third-generation anti-seizure medications (ASMs), approximately 40% of people with epilepsy present drug-resistant epilepsy (DRE). Cenobamate is the first ASM approved in Spain for the adjunctive treatment of Focal-Onset Seizures (FOS) in adult patients with DRE. In a chronic disease with a portfolio of available ASMs, the decision to introduce a new therapeutic alternative must follow a holistic evaluation of value provided. Reflective Multi-Criteria Decision Analysis (MCDA) methodology allows to determine the value contribution of a treatment in a given indication considering all relevant criteria for healthcare decision-making in a transparent and systematic manner from the perspective of relevant stakeholders. PURPOSE The aim of this study was to determine the relative value contribution of cenobamate in the treatment of FOS in patients with DRE compared with third-generation ASMs using reflective MCDA-based methodology. METHODS A systematic literature review (combining biomedical databases and grey literature sources) was performed to populate the Evidence and Value: Impact on DEcisionMaking (EVIDEM) MCDA framework adapted to determine what represents value in the management of FOS in patients with DRE in Spain. The study was conducted in two phases. The first took place in 2021 with a multi-stakeholder group of eight participants. The second phase was conducted in 2022 with a multi-stakeholder group of 32 participants. Participants were trained in MCDA methodology and scored four evidence matrices (cenobamate vs. brivaracetam, vs. perampanel, vs. lacosamide and vs. eslicarbazepine acetate). Results were analyzed and discussed in a group meeting through reflective MCDA discussion methodology. RESULTS DRE is considered a very severe condition associated with many important unmet needs, mainly with regard to the lack of more effective treatments to achieve the ultimate goal of treatment. Compared to third-generation ASMs, cenobamate is perceived to have a better efficacy profile based on improvements in responder rate and seizure freedom. Regarding safety, it is considered to have a similar profile to alternatives and a positive quality-of-life profile. Cenobamate results in lower direct medical costs (excluding pharmacological) and indirect costs. Overall, cenobamate is regarded as providing a high therapeutic impact and supported by high-quality evidence. CONCLUSIONS Based on reflective MCDA methodology and stakeholders' experience in clinical management of epilepsy in Spain, cenobamate is perceived as a value-added option for the treatment of patients with DRE when compared with third-generation ASMs.
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Affiliation(s)
| | | | | | | | - Javier Montoya
- Hospital General Universitario de Valencia, Comunidad Valenciana, Spain
| | | | | | - Elías Ruiz
- Hospital General Universitario de Valencia, Comunidad Valenciana, Spain
| | | | | | | | | | | | | | - Alicia Gil
- Omakase Consulting S.L., Barcelona, Spain.
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Kerr WT, Auvin S, Van der Geyten S, Kenney C, Novak G, Fountain NB, Grzeskowiak C, French JA. Time-to-event clinical trial designs: Existing evidence and remaining concerns. Epilepsia 2023; 64:1699-1708. [PMID: 37073881 PMCID: PMC10524279 DOI: 10.1111/epi.17621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/17/2023] [Accepted: 04/18/2023] [Indexed: 04/20/2023]
Abstract
Well-designed placebo-controlled clinical trials are critical to the development of novel treatments for epilepsy, but their design has not changed for decades. Patients, clinicians, regulators, and innovators all have concerns that recruiting for trials is challenging, in part, due to the static design of maintaining participants for long periods on add-on placebo when there are an increasing number of options for therapy. A traditional trial maintains participants on blinded treatment for a static period (e.g., 12 weeks of maintenance), during which participants on placebo have an elevated risk of sudden unexpected death in epilepsy compared to patients on an active treatment. Time-to-event trials observe participants on blinded treatment until a key event occurs (e.g., post-randomization seizure count matches pre-randomization monthly seizure count). In this article, we review the evidence for these designs based on re-analysis of prior trials, one published trial that used a time-to-second seizure design, and experience from an ongoing blinded trial. We also discuss remaining concerns regarding time-to-event trials. We conclude that, despite potential limitations, time-to-event trials are a potential promising mechanism to make trials more patient friendly and reduce placebo exposure, which are urgent needs to improve safety and increase recruitment to trials.
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Affiliation(s)
- Wesley T. Kerr
- Department of Neurology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Stéphane Auvin
- Assistance Publique-Hôpitaux de Paris, Service de Neurologie Pédiatrique, Hôpital Robert Debré, Paris, France
- Université Paris-Cité, Institut National de la Santé et de la Recherche Médicale NeuroDiderot, Paris, France
- Institut Universitaire de France, Paris, France
| | - Serge Van der Geyten
- Janssen Research & Development, a Division of Janssen Pharmaceutica NV, Beerse, Belgium
| | | | - Gerald Novak
- Janssen Research & Development, a Division of Janssen Pharmaceutica NV, Beerse, Belgium
| | - Nathan B. Fountain
- Department of Neurology, University of Virginia, Charlottesville, Virginia, USA
| | - Caitlin Grzeskowiak
- Research and New Therapies Program, Epilepsy Foundation of America, Maryland, USA
| | - Jacqueline A. French
- Comprehensive Epilepsy Center, New York University, New York City, New York, USA
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French JA, Cleary E, Dlugos D, Farfel G, Farrell K, Gidal B, Grzeskowiak CL, Gurrell R, Harden C, Stalvey TJ, Tsai J, Wirrell EC, Blum D, Fountain N. Considerations for determining the efficacy of new antiseizure medications in children age 1 month to younger than 2 years. Epilepsia 2022; 63:2664-2670. [PMID: 35835554 PMCID: PMC9804346 DOI: 10.1111/epi.17366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/12/2022] [Accepted: 07/12/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Drug treatment for children with epilepsy should, ideally, be governed by evidence from adequate and well-controlled clinical studies. However, these studies are difficult to conduct, and so direct evidence supporting the informed use of specific drugs is often lacking. The Research Roundtable for Epilepsy (RRE) met in 2020 to align on an approach to therapy development for focal seizures in children age 1 month <2 years of age. METHODS The RRE reviewed the regulatory landscape, epidemiology, seizure semiology, antiseizure medicine pharmacology, and safety issues applicable to this population. RESULTS After reviewing evidence, the conclusion was that pediatric efficacy trials would be impracticable to conduct but a waiver of the regulatory requirement to conduct any study would lead to an absence of information to guide dosing in a critical population. Review of available data and discussion of RRE attendees led to the conclusion that the requirements for extrapolation of efficacy from older children down to infants from age 1 month to <2 years old appeared to be met. After the RRE, the US Food and Drug Administration (FDA) approved brivaracetam for use in children with focal epilepsy above the age of 1 month in August 2021 and lacosamide in October 2021, both based on the principle of extrapolation from data in older children. SIGNIFICANCE These recommendations should result in more rapid accessibility of antiseizure medications for infants.
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Affiliation(s)
| | | | - Dennis Dlugos
- Departments of Neurology and PediatricsChildren's Hospital of Philadelphia, PerelmanPhiladelphiaPennsylvaniaUSA
| | - Gail Farfel
- Zogenix, a UCB CompanyEmeryvilleCaliforniaUSA
| | - Kathleen Farrell
- Research and New Therapies ProgramEpilepsy Foundation of AmericaMarylandUSA
| | - Barry Gidal
- University of Wisconsin School of PharmacyMadisonWisconsinUSA
| | | | | | - Cynthia Harden
- Clinical Development DivisionXenon Pharmaceuticals Inc.BurnabyBritish ColumbiaCanada
| | | | | | - Elaine C. Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Department of NeurologyMayo ClinicRochesterMinnesotaUSA
| | | | - Nathan Fountain
- Department of NeurologyUniversity of VirginiaCharlottesvilleVirginiaUSA
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Kriechbaumer SRP, Jurina K, Wielaender F, Schenk HC, Steinberg TA, Reese S, Buhmann G, Doerfelt S, Potschka H, Fischer A. Pregabalin Add-On vs. Dose Increase in Levetiracetam Add-On Treatment: A Real-Life Trial in Dogs With Drug-Resistant Epilepsy. Front Vet Sci 2022; 9:910038. [PMID: 35873699 PMCID: PMC9298511 DOI: 10.3389/fvets.2022.910038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
Epilepsy is a common neurological disorder affecting 0.6–0.75% of dogs in veterinary practice. Treatment is frequently complicated by the occurrence of drug-resistant epilepsy and cluster seizures in dogs with idiopathic epilepsy. Only few studies are available to guide treatment choices beyond licensed veterinary drugs. The aim of the study was to compare antiseizure efficacy and tolerability of two add-on treatment strategies in dogs with drug-resistant idiopathic epilepsy. The study design was a prospective, open-label, non-blinded, comparative treatment trial. Treatment success was defined as a 3-fold extension of the longest baseline interseizure interval and to a minimum of 3 months. To avoid prolonged adherence to a presumably ineffective treatment strategy, dog owners could leave the study after the third day with generalized seizures if the interseizure interval failed to show a relevant increase. Twenty-six dogs (mean age 5.5 years, mean seizure frequency 4/month) with drug-resistant idiopathic epilepsy and a history of cluster seizures were included. Dogs received either add-on treatment with pregabalin (PGB) 4 mg/kg twice daily (14 dogs) or a dose increase in levetiracetam (LEV) add-on treatment (12 dogs). Thirteen dogs in the PGB group had drug levels within the therapeutic range for humans. Two dogs in the PGB group (14.3%; 2/14) and one dog in the LEV group (8.3%; 1/12) achieved treatment success with long seizure-free intervals from 122 to 219 days but then relapsed to their early seizure frequency 10 months after the study inclusion. The overall low success rates with both treatment strategies likely reflect a real-life situation in canine drug-resistant idiopathic epilepsy in everyday veterinary practice. These results delineate the need for research on better pharmacologic and non-pharmacologic treatment strategies in dogs with drug-resistant epilepsy.
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Affiliation(s)
- Sandra R. P. Kriechbaumer
- Centre for Clinical Veterinary Medicine, Clinic of Small Animal Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
- AniCura Small Animal Clinic Haar, Haar, Germany
| | | | - Franziska Wielaender
- Centre for Clinical Veterinary Medicine, Clinic of Small Animal Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Henning C. Schenk
- Centre for Clinical Veterinary Medicine, Clinic of Small Animal Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
- Small Animal Clinic Lüneburg, Lüneburg, Germany
| | | | - Sven Reese
- Department of Veterinary Sciences, Institute of Anatomy, Histology and Embryology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Gesine Buhmann
- Centre for Clinical Veterinary Medicine, Clinic of Small Animal Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Stefanie Doerfelt
- Centre for Clinical Veterinary Medicine, Clinic of Small Animal Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
- AniCura Small Animal Clinic Haar, Haar, Germany
| | - Heidrun Potschka
- Department of Veterinary Sciences, Institute of Pharmacology, Toxicology, and Pharmacy, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Andrea Fischer
- Centre for Clinical Veterinary Medicine, Clinic of Small Animal Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
- *Correspondence: Andrea Fischer
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Hamer HM, Holtkamp M, Kaiser T, Fey S, Rozinat K, Mayer T, Schulze-Bonhage A. Position paper of a German interdisciplinary round table on future designs of trials on adjunctive treatment with antiseizure drugs. Seizure 2020; 78:53-56. [PMID: 32200190 DOI: 10.1016/j.seizure.2020.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 03/05/2020] [Accepted: 03/06/2020] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Current trials on adjunctive treatment with antiseizure drugs often do not reveal results which are relevant for clinical practice. METHOD Therefore, an interdisciplinary group of German experts discussed a new framework for future antiseizure drug (ASD) trials in adults. This group included members of the executive board of the German Society of Epileptology, of the German institutes for health technology assessment (HTA), of patient organizations and of drug manufacturers. Agreement was reached by consensus decision making after intensive discussion of the findings of a narrative review of the current literature. RESULTS The group jointly recommends that ASD trials in adults should be based on and include relevant patient groups, e.g. elderly patients and patients with relevant co-morbidities, should adopt a study duration of at least 12 months, should avoid placebo arms, should include active comparators of clinical relevance, may be designed as open label trials with blinded outcome measurements, should focus on patient relevant outcomes that reflect the impact of benefits and harms of treatments on daily living, such as seizure freedom and seizure severity as well as retention rate, functional outcomes and quality of life as compound measures, and should avoid arbitrary and non-sensitive primary endpoints such as dichotomized changes in seizure frequency. CONCLUSIONS This paper focused on improved head-to-head trials on adjunctive treatment with antiseizure drugs. The group welcomes any further work and discussion to enhance future studies which can be applied to the entire spectrum of potentially meaningful study populations and outcomes.
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Affiliation(s)
- Hajo M Hamer
- Epilepsy Center, Dept. of Neurology, University of Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany.
| | - Martin Holtkamp
- Epilepsy-Center Berlin-Brandenburg, Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Thomas Kaiser
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670 Cologne, Germany
| | - Susanne Fey
- e.b.e. Epilepsie Bundes-Elternverband e.V., Am Eickhof 23, 42111 Wuppertal, Germany
| | - Klaus Rozinat
- Deutsche Epilepsievereinigung e.V., Zillestraße 102, 10585 Berlin, Germany
| | - Thomas Mayer
- Sächsisches Epilepsiezentrum Radeberg, Wachauer Str. 30, D01454 Radeberg, Germany
| | - Andreas Schulze-Bonhage
- Epilepsy Center, University Medical Center Freiburg, Faculty of Medicine, Breisacher Str. 64, D-79106 Freiburg, Germany
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Oliveira A, Romero JM, Goldenholz DM. Comparing the efficacy, exposure, and cost of clinical trial analysis methods. Epilepsia 2019; 60:e128-e132. [DOI: 10.1111/epi.16384] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/17/2019] [Accepted: 10/18/2019] [Indexed: 11/27/2022]
Affiliation(s)
| | - Juan M. Romero
- Beth Israel Deaconess Medical Center Boston Massachusetts
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Cagnotti G, Odore R, Bertone I, Corona C, Dappiano E, Gardini G, Iulini B, Bellino C, D'Angelo A. Open-label clinical trial of rectally administered levetiracetam as supplemental treatment in dogs with cluster seizures. J Vet Intern Med 2019; 33:1714-1718. [PMID: 31218767 PMCID: PMC6639497 DOI: 10.1111/jvim.15541] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 05/17/2019] [Indexed: 01/09/2023] Open
Abstract
Background Treatment options for at‐home management of cluster seizures (CS) and status epilepticus (SE) are limited. The pharmacokinetics of levetiracetam (LEV) after rectal administration in both healthy and epileptic dogs has been investigated recently. Hypothesis/Objectives To investigate the clinical efficacy of rectally administered LEV in preventing additional seizures in dogs presented for CS and SE. We hypothesized that rectal administration of LEV in addition to a standard treatment protocol would provide better control of seizure activity as compared with the standard treatment protocol alone. Animals Fifty‐seven client‐owned dogs with CS or SE. Methods Prospective open‐label clinical trial. Patients included in the study were assigned to receive either a standard treatment protocol comprising IV/rectal diazepam and IV phenobarbital q8h (control group) or a standard treatment protocol in association with a single dose of 40 mg/kg LEV rectally (rectal LEV group). Dogs that experienced no additional seizures were defined as responders, whereas those that showed additional seizure activity were classified as nonresponders. Results Twenty‐one dogs were assigned to the rectal LEV group, and 36 to control group. Given the small number of cases of SE, statistical analysis was performed only on patients with CS. The response rate was 94% in the rectal LEV group and 48% in the control group (P < .001). Conclusions and Clinical Importance Rectally administered LEV combined with a standard treatment protocol provided good control of seizure activity in patients with CS. The validity of these results should be confirmed in a double‐blinded, placebo‐controlled clinical trial.
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Affiliation(s)
- Giulia Cagnotti
- Department of Veterinary Science, University of Turin, Turin, Italy
| | - Rosangela Odore
- Department of Veterinary Science, University of Turin, Turin, Italy
| | - Iride Bertone
- Department of Veterinary Science, University of Turin, Turin, Italy
| | - Cristiano Corona
- Istituto Zooprofilattico del Piemonte Liguria e Valle d'Aosta, Turin, Italy
| | - Elena Dappiano
- Department of Veterinary Science, University of Turin, Turin, Italy
| | - Giulia Gardini
- Department of Veterinary Science, University of Turin, Turin, Italy
| | - Barbara Iulini
- Istituto Zooprofilattico del Piemonte Liguria e Valle d'Aosta, Turin, Italy
| | - Claudio Bellino
- Department of Veterinary Science, University of Turin, Turin, Italy
| | - Antonio D'Angelo
- Department of Veterinary Science, University of Turin, Turin, Italy
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Witek N, Stebbins GT, Goetz CG. What influences placebo and nocebo responses in Parkinson's disease? Mov Disord 2018; 33:1204-1212. [DOI: 10.1002/mds.27416] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 03/27/2018] [Accepted: 03/29/2018] [Indexed: 12/17/2022] Open
Affiliation(s)
- Natalie Witek
- Rush Parkinson's Disease and Movement Disorders Program; Chicago Illinois USA
| | - Glenn T. Stebbins
- Rush Parkinson's Disease and Movement Disorders Program; Chicago Illinois USA
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Abstract
Rational prescribing should be based on the assessment of high-quality evidence about the benefits and risks of available treatment options. Because clinical trials, particularly randomized controlled trials (RCTs), provide the best source of evidence, their design and results need to be carefully scrutinized. The majority of RCTs of antiepileptic drugs (AEDs) have been designed to address regulatory requirements, and generally they involve restrictive eligibility criteria, rigid dosing schemes, short duration of follow-up, and comparison with placebo rather than standard treatments. Although these studies have high internal validity, they are conducted in a setting that is distant from routine clinical practice and therefore their usefulness in guiding treatment decisions is limited. Information more directly applicable to clinical practice can be derived from a relatively small number of comparative effectiveness monotherapy RCTs, although the design of some of these studies was probably biased in favor of the sponsor's product. Alarmingly, there is a paucity of well-designed trials in epilepsy syndromes other than focal epilepsies, and no RCTs at all in most of the less common epileptic syndromes of infancy and childhood. In the light of these shortcomings, there is scope for re-assessing regulatory requirements to facilitate generation of data more directly applicable to the routine clinical setting. Likewise, research-funding organizations should be sensitized about the lack of adequate evidence to guide therapeutic practice in epilepsy, and the need to promote high-quality comparative effectiveness trials. Future prospective pragmatic trials may benefit from the increasingly widespread availability of electronic health records.
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Affiliation(s)
- Emilio Perucca
- Division of Clinical and Experimental Pharmacology Department of Internal Medicine and Therapeutics University of Pavia Pavia Italy.,Clinical Trial Center IRCCS Mondino Foundation Pavia Italy
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