Treatment of myoclonic seizures in patients with juvenile myoclonic epilepsy

Role of Perampanel in the Management of Pediatric Epilepsies in Asia: Expert Opinion

Management of pediatric epilepsies poses unique challenges around diagnosis, treatment options, comorbidities, and the potential for these factors to interact with processes in the developing brain. In pediatric patients, broad-spectrum antiseizure medications (ASMs) with minimal potential for adverse events (AEs) and limited impact on cognition and behavior are preferred. Perampanel is a first-in-class ASM with broad-spectrum efficacy, a tolerable safety profile, minimal negative impact on cognitive function, and other features that make it a viable treatment option in this patient population. However, evidence and experience of its use in pediatric patients are less extensive than in adult patients. Experts in pediatric epilepsy across the region convened at a series of meetings to discuss the use of perampanel in pediatric patients, including dose optimization, AE prevention and management, and considerations in particular groups. This article summarizes key evidence for perampanel in the pediatric population and consolidates the experts' recommendations for using the ASM in managing pediatric epilepsies.

Prevalence of Medically Resistant Epilepsy in Saudi Arabia

OBJECTIVES

The objective of this study was to evaluate the prevalence of medically resistant epilepsy (MRE) in our hospital and to compare the prevalence with that in other populations.

METHODS

We retrospectively analyzed the data of patients who visited the epilepsy clinics at King Fahd University Hospital, Al-Khobar, Saudi Arabia between January 2017 and December 2018. This study included patients aged ≥14 years who had at least 2 unprovoked seizures 24 h apart. Patients who had provoked seizure(s), paroxysmal events, or syncope or had incomplete medical records were excluded. The definition and classification of the International League Against Epilepsy were used. Moreover, we searched the En-glish literature using PubMed and Google Scholar to compare the prevalence of MRE between our population and other populations.

RESULTS

In total, 1,151 patients were screened, and 751 patients were included in the final analysis. Of the 751 patients, 229 (male: 56.3%, female: 43.7%; mean age: 32.07 years, and standard deviation, 12.2 years) had MRE, with a cumulative prevalence of 30%. The etiology was as follows: unknown, 63.3% (n = 145); structural, 31.9% (n = 73); genetic, 3.1% (n = 7); and infectious, 1.7% (n = 4). None of the patients had metabolic or immune-related etiologies.

CONCLUSION

The prevalence of MRE in our population (30%) is close to that in other populations (30-36.5%). Early identification of such patients is crucial to improve their management.

Pharmacotherapy for Focal Seizures in Children and Adolescents

Focal-onset seizures are among the most common forms of seizures in children and adolescents and can be caused by a wide diversity of acquired or genetic etiologies. Despite the increasing array of antiseizure drugs available, treatment of focal-onset seizures in this population remains problematic, with as many as one-third of children having seizures refractory to medications. This review discusses contemporary concepts in focal seizure classification and pathophysiology and describes the antiseizure medications most commonly chosen for this age group. As antiseizure drug efficacy is comparable in children and adults, here we focus on pharmacokinetic aspects, drug-drug interactions, and side effect profiles. Finally, we provide some suggestions for choosing the optimal medication for the appropriate patient.

High-dose versus low-dose valproate for the treatment of juvenile myoclonic epilepsy: Going from low to high

Juvenile myoclonic epilepsy (JME) is a genetic generalized epilepsy accounting for 3-12% of adult cases of epilepsy. Valproate has proven to be the first-choice drug in JME for controlling the most common seizure types: myoclonic, absence, and generalized tonic-clonic (GTC). In this retrospective study, we analyzed seizure outcome in patients with JME using valproate monotherapy for a minimum period of one year. Low valproate dose was considered to be 1000mg/day or lower, while serum levels were considered to be low if they were at or below 50mcg/dl. One hundred three patients met the inclusion criteria. Fifty-six patients (54.4%) were female. The current average age was 28.4±7.4years, while the age of epilepsy onset was 13.6±2.9years. Most patients corresponded to the subsyndrome of classic JME. Forty-six (44.7%) patients were free from all seizure types, and 76 (73.7%) patients were free from GTC seizures. No significant difference was found in seizure freedom among patients using a low dose of valproate versus a high dose (p=0.535) or among patients with low blood levels versus high blood levels (p=0.69). In patients with JME, it seems appropriate to use low doses of valproate (500mg to 1000mg) for initial treatment and then to determine if freedom from seizures was attained.