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Polet SS, de Koning TJ, Lambrechts RA, Tijssen MAJ, Sibon OCM, Gorter JA. Conventional and novel anti-seizure medications reveal a particular role for GABA A in a North Sea progressive myoclonus Epilepsy Drosophila model. Epilepsy Res 2024; 203:107380. [PMID: 38781737 DOI: 10.1016/j.eplepsyres.2024.107380] [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: 12/18/2023] [Revised: 04/01/2024] [Accepted: 05/06/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE North Sea Progressive Myoclonus Epilepsy (NS-PME) is a rare genetic disorder characterized by ataxia, myoclonus and seizures with a progressive course. Although the cause of NS-PME is known, namely a homozygous mutation in the GOSR2 gene (c.430 G>T; p. Gly144Trp), sufficient treatment is lacking. Despite combinations of on average 3-5 anti-seizure medications (ASMs), debilitating myoclonus and seizures persist. Here we aimed to gain insight into the most effective anti-convulsive target in NS-PME by evaluating the individual effects of ASMs in a NS-PME Drosophila model. METHOD A previously generated Drosophila model for NS-PME was used displaying progressive heat-sensitive seizures. We used this model to test 1. a first-generation ASM (sodium barbital), 2. common ASMs used in NS-PME (clonazepam, valproic acid, levetiracetam, ethosuximide) and 3. a novel third-generation ASM (ganaxolone) with similar mode of action to sodium barbital. Compounds were administered by adding them to the food in a range of concentrations. After 7 days of treatment, the percentage of heat-induced seizures was determined and compared to non-treated but affected controls. RESULTS As previously reported in the NS-PME Drosophila model, sodium barbital resulted in significant seizure suppression, with increasing effect at higher dosages. Of the commonly prescribed ASMs, clonazepam and ethosuximide resulted in significant seizure suppression, whereas both valproic acid and levetiracetam did not show any changes in seizures. Interestingly, ganaxolone did result in seizure suppression as well. CONCLUSION Of the six drugs tested, three of the four that resulted in seizure suppression (sodium barbital, clonazepam, ganaxolone) are primary known for their direct effect on GABAA receptors. This suggests that GABAA could be a potentially important target in the treatment of NS-PME. Consequently, these findings add rationale to the exploration of the clinical effect of ganaxolone in NS-PME and other progressive myoclonus epilepsies.
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Affiliation(s)
- Sjoukje S Polet
- Department of Neurology, University Medical Center Groningen, University of Groningen, 30.001 AB51, Groningen 9700 RB, the Netherlands; Expertise Center Movement Disorders Groningen, University Medical Center Groningen, University of Groningen, 30.001 AB51, Groningen 9700 RB, the Netherlands.
| | - Tom J de Koning
- Expertise Center Movement Disorders Groningen, University Medical Center Groningen, University of Groningen, 30.001 AB51, Groningen 9700 RB, the Netherlands; Department of Neurology and Medical Genetics, University Medical Center Groningen, University of Groningen, 30.001 AB51, Groningen 9700 RB, the Netherlands; Department of Clinical Sciences, Pediatrics, Lund University, Lund BMC I12, 221 84, Sweden
| | - Roald A Lambrechts
- Expertise Center Movement Disorders Groningen, University Medical Center Groningen, University of Groningen, 30.001 AB51, Groningen 9700 RB, the Netherlands; Department of Neurology, University Medical Center Groningen, University of Groningen, 30.001 AB51, Groningen 9700 RB, the Netherlands
| | - Marina A J Tijssen
- Expertise Center Movement Disorders Groningen, University Medical Center Groningen, University of Groningen, 30.001 AB51, Groningen 9700 RB, the Netherlands; Department of Neurology, University Medical Center Groningen, University of Groningen, 30.001 AB51, Groningen 9700 RB, the Netherlands
| | - Ody C M Sibon
- Expertise Center Movement Disorders Groningen, University Medical Center Groningen, University of Groningen, 30.001 AB51, Groningen 9700 RB, the Netherlands; Department of Biomedical Sciences (BMS), University Medical Center Groningen, University of Groningen, 30.001 FB32, Groningen 9700 AD, the Netherlands
| | - Jenke A Gorter
- Expertise Center Movement Disorders Groningen, University Medical Center Groningen, University of Groningen, 30.001 AB51, Groningen 9700 RB, the Netherlands; Department of Biomedical Sciences (BMS), University Medical Center Groningen, University of Groningen, 30.001 FB32, Groningen 9700 AD, the Netherlands
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Lesné L, Desdoits-Lethimonier C, Hug E, Costet N, Raffenne L, Toupin M, Evrard B, Kugathas I, Lavoué V, Chalmel F, Jégou B, Mazaud-Guittot S. Antiepileptic drugs are endocrine disruptors for the human fetal testis ex vivo. Toxicol Sci 2023; 195:169-183. [PMID: 37505509 DOI: 10.1093/toxsci/kfad076] [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] [Indexed: 07/29/2023] Open
Abstract
Valproic acid (VPA) has long been the most widely used antiepileptic drug (AED) for the treatment of epilepsy, bipolar psychiatric disorders, and migraine. However, long-term VPA treatment has several adverse effects on the male reproductive system notably on endocrine functions and/or spermatic parameters. In utero exposure of the fetus to VPA is well known to be associated with a higher risk of several congenital malformations including those of male reproductive organs. Subsequent generations of AEDs, such as carbamazepine (CARB) and lamotrigine (LAM), are considered safer and are currently recommended for women of child-bearing age with epilepsy. Because anomalies of the male genital tract mostly result from endocrine imbalance during fetal life, we hypothesized that AEDs could directly impair testis differentiation. We thus aimed at identifying and characterizing the effects of VPA, CARB, and LAM on the differentiation and function of the different testicular cell types, and at understanding the mechanisms underlying these effects. By using ex vivo culture of first-trimester human fetal testes, we show that VPA induces multiple endocrine disruptive effects, compared with the milder ones caused by CARB and LAM. AED also subtly altered the germ cell lineage in distinct manners. Transcriptomic analysis of VPA-induced alterations highlighted a very broad range of effects on the fetal testis. Overall, our results show that AEDs can behave as endocrine disruptors for the human fetal testis ex vivo. This is consistent with, and likely underlies, the VPA-induced male genital tract masculinization abnormalities observed in patients.
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Affiliation(s)
- Laurianne Lesné
- Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, 35000 Rennes, France
| | - Christèle Desdoits-Lethimonier
- Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, 35000 Rennes, France
| | - Elisa Hug
- Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, 35000 Rennes, France
| | - Nathalie Costet
- Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, 35000 Rennes, France
| | - Léo Raffenne
- Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, 35000 Rennes, France
| | - Maryne Toupin
- Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, 35000 Rennes, France
| | - Bertrand Evrard
- Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, 35000 Rennes, France
| | - Indusha Kugathas
- Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, 35000 Rennes, France
| | - Vincent Lavoué
- Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, 35000 Rennes, France
| | - Frédéric Chalmel
- Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, 35000 Rennes, France
| | - Bernard Jégou
- Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, 35000 Rennes, France
- EHESP-School of Public Health, 35043 Rennes, France
| | - Séverine Mazaud-Guittot
- Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, 35000 Rennes, France
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3
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Koekkoek JAF, van der Meer PB, Pace A, Hertler C, Harrison R, Leeper HE, Forst DA, Jalali R, Oliver K, Philip J, Taphoorn MJB, Dirven L, Walbert T. Palliative care and end-of-life care in adults with malignant brain tumors. Neuro Oncol 2023; 25:447-456. [PMID: 36271873 PMCID: PMC10013651 DOI: 10.1093/neuonc/noac216] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND This systematic review provides updated insights, from the published literature in the past 5 years, based on the 2017 European Association of Neuro-Oncology (EANO) guidelines for palliative care in adults with malignant brain tumors. It provides an overview of palliative care options, including during the end-of-life phase for patients with malignant brain tumors. METHODS A systematic literature search was conducted from 2016 to 2021 focusing on four main topics: (1) symptom management, (2) caregiver needs, (3) early palliative care, and (4) care in the end-of-life phase. An international panel of palliative care experts in neuro-oncology synthesized the literature and reported the most relevant updates. A total of 140 articles were included. RESULTS New insights include that: Hippocampal avoidance and stereotactic radiosurgery results in a lower risk of neurocognitive decline in patients with brain metastases; levetiracetam is more efficacious in reducing seizures than valproic acid as first-line monotherapy antiseizure drug (ASD) in glioma patients; lacosamide and perampanel seem well-tolerated and efficacious add-on ASDs; and a comprehensive framework of palliative and supportive care for high-grade glioma patients and their caregivers was proposed. No pharmacological agents have been shown in randomized controlled trials to significantly improve fatigue or neurocognition. CONCLUSIONS Since the 2017 EANO palliative care guidelines, new insights have been reported regarding symptom management and end-of-life care, however, most recommendations remain unchanged. Early palliative care interventions are essential to define goals of care and minimize symptom burden in a timely fashion. Interventional studies that address pain, fatigue, and psychiatric symptoms as well as (the timing of) early palliative care are urgently needed.
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Affiliation(s)
- Johan A F Koekkoek
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Pim B van der Meer
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Andrea Pace
- Neuro-Oncology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Caroline Hertler
- Competence Center Palliative Care, Department of Radiation Oncology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Rebecca Harrison
- Division of Medical Oncology, BC Cancer, The University of British Colombia, Vancouver, Canada
| | - Heather E Leeper
- Neuro-Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland,USA
| | - Deborah A Forst
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Rakesh Jalali
- Department of Radiation Oncology, Apollo Proton Cancer Center, Chennai, India
| | - Kathy Oliver
- International Brain Tumour Alliance, Tadworth, UK
| | - Jennifer Philip
- Department of Medicine, St. Vincent’s Hospital Melbourne, University of Melbourne, Victoria, Australia
| | - Martin J B Taphoorn
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Linda Dirven
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Tobias Walbert
- Department of Neurology and Neurosurgery, Henry Ford Health System and Department of Neurology Wayne State University, Detroit, Michigan, USA
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Rana RR, Rajasekaran K, Knappertz V, Gray RA. Pharmacodynamic synergism contributes to the antiseizure action of cannabidiol and clobazam. Exp Neurol 2023; 360:114286. [PMID: 36442674 DOI: 10.1016/j.expneurol.2022.114286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/21/2022] [Accepted: 11/23/2022] [Indexed: 11/27/2022]
Abstract
The management of refractory epilepsy involves treatment with more than one antiseizure medication (ASM). Combination of ASMs with distinct mechanisms of action are hypothesized to improve overall treatment effectiveness. In clinical trials, concomitant use of cannabidiol (CBD) and clobazam (CLB) was associated with increased seizure reduction and bidirectional elevation in levels of their active metabolites, 7-hydroxy-cannabidiol (7-OH-CBD) and nor-clobazam (n-CLB). Using isobolographic analysis, we investigated whether CBD and CLB interacted pharmacodynamically. In the mouse maximal electroshock seizure (MES) test, brain tissue levels of CBD and CLB corresponding to seizure prevention in 50% of animals (brain Effective Exposure, bEE50) were 7.9 μM and 1.6 μM, respectively. In the 6 Hz psychomotor seizure model, 7-OH-CBD displayed a 5-fold greater potency than CBD (b-EE50, 8.7 μM vs 47.3 μM). Isobolographic analysis performed on combination of CBD/CLB at 1:1, 3:1, and 1:3 ratios based on equi-effective bEE50 values revealed synergism at all doses with combination indices (CI) of 0.43, 0.62 and 0.75 respectively. These outcomes were independent of pharmacokinetic interaction between CBD and CLB. These findings identify pharmacodynamic synergism as an important factor underlying enhanced antiseizure effect during concomitant CBD and CLB use.
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Tantsura LM, Pylypets OY, Tretiakov DV, Tantsura YO. VARIANTS OF THE FORMATION AND COURSE OF DRUG-RESISTANT EPILEPSY IN CHILDREN WITH GENETIC POLYMORPHISMS OF CYP2C9, CYP2C19, CYP3A4. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2023; 76:1007-1013. [PMID: 37326083 DOI: 10.36740/wlek202305118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
OBJECTIVE The aim: To clarify the frequency with which various variants of the formation and course of drug-resistant epilepsy occur in children with genetic polymor¬phisms of cytochromes CYP2C9, CYP2C19, CYP3A4. PATIENTS AND METHODS Materials and methods: The genotyping of CYP2C9*2, CYP2C9*3, CYP2C19*2, CYP3A4*1B by the allele-specific polymerase chain reaction was performed in 116 children with drug-resistant epilepsy aged from 2 to 17 years. Thirty cases (boys-15; girls-15) with a follow-up period of more than 5 years were analyzed in detail. RESULTS Results: Of 30 cases analyzed, polymorphisms were not detected in 8 (26.67%) children, and 22 (73.33%) had polymorphisms of the CYP2C9, CYP2C19 and CYP3A4 genes associated with a slow metabolism of AED. In children with polymorphisms of the CYP450 genes, the wave-like course of the disease with the periods of remission and its failures was characteristic, while for children with a presumably normal metabolism there was the initial resistance to the treatment with AED. CONCLUSION Conclusions: Individual changes in the AED metabolism affect the course of drug-resistant epilepsies. For patients with a slow metabolism of AED the wave-like course of the disease and the "slipping off" phenomenon were more characteristic.
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Affiliation(s)
- Liudmyla M Tantsura
- SI "INSTITUTE OF NEUROLOGY, PSYCHIATRY AND NARCOLOGY, NAMS OF UKRAINE", KHARKIV, UKRAINE
| | - Olena Yu Pylypets
- SI "INSTITUTE OF NEUROLOGY, PSYCHIATRY AND NARCOLOGY, NAMS OF UKRAINE", KHARKIV, UKRAINE
| | - Dmytro V Tretiakov
- SI "INSTITUTE OF NEUROLOGY, PSYCHIATRY AND NARCOLOGY, NAMS OF UKRAINE", KHARKIV, UKRAINE
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Tesiye MR, Gol M, Fadardi MR, Kani SNM, Costa AM, Ghasemi-Kasman M, Biagini G. Therapeutic Potential of Mesenchymal Stem Cells in the Treatment of Epilepsy and Their Interaction with Antiseizure Medications. Cells 2022; 11:cells11244129. [PMID: 36552892 PMCID: PMC9777461 DOI: 10.3390/cells11244129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 12/11/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
Epilepsy is a life-threatening neurological disease that affects approximately 70 million people worldwide. Although the vast majority of patients may be successfully managed with currently used antiseizure medication (ASM), the search for alternative therapies is still necessary due to pharmacoresistance in about 30% of patients with epilepsy. Here, we review the effects of ASMs on stem cell treatment when they could be, as expected, co-administered. Indeed, it has been reported that ASMs produce significant effects on the differentiation and determination of stem cell fate. In addition, we discuss more recent findings on mesenchymal stem cells (MSCs) in pre-clinical and clinical investigations. In this regard, their ability to differentiate into various cell types, reach damaged tissues and produce and release biologically active molecules with immunomodulatory/anti-inflammatory and regenerative properties make them a high-potential therapeutic tool to address neuroinflammation in different neurological disorders, including epilepsy. Overall, the characteristics of MSCs to be genetically engineered, in order to replace dysfunctional elements with the aim of restoring normal tissue functioning, suggested that these cells could be good candidates for the treatment of epilepsy refractory to ASMs. Further research is required to understand the potential of stem cell treatment in epileptic patients and its interaction with ASMs.
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Affiliation(s)
- Maryam Rahimi Tesiye
- Faculty of Life Science and Biotechnology, Shahid Beheshti University, Tehran 19839-69411, Iran
| | - Mohammad Gol
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41125 Modena, Italy
- PhD School of Clinical and Experimental Medicine (CEM), University of Modena and Reggio Emilia, 41125 Modena, Italy
| | | | | | - Anna-Maria Costa
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Maryam Ghasemi-Kasman
- Cellular and Molecular Biology Research Center, Health Research Institute, Babol University of Medical Sciences, Babol 47176-47745, Iran
- Department of Physiology, School of Medical Sciences, Babol University of Medical Sciences, Babol 47176-47745, Iran
- Correspondence: (M.G.-K.); (G.B.)
| | - Giuseppe Biagini
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41125 Modena, Italy
- Correspondence: (M.G.-K.); (G.B.)
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Dwivedi R, Tiwari P, Pahuja M, Dada R, Tripathi M. Anti-seizure medications and quality of life in person with epilepsy. Heliyon 2022; 8:e11073. [PMID: 36281370 PMCID: PMC9586904 DOI: 10.1016/j.heliyon.2022.e11073] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 09/14/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022] Open
Abstract
Objective The goal of this study was to determine the effects of mono-, bi-, and polytherapy anti-seizure medications (ASMs) in terms of seizure reduction and quality of life (QOL) in persons with epilepsy (PWE). Methods A cross-sectional observational study was conducted. All PWE with age <75 years were recruited and further classified into two groups: responders and non-responders, based on the response of the ASMs to the treatments for reduced seizure frequency since the last one year. Other demographic and clinical data such as seizure frequency, type of seizures, age at onset of seizures, and information about ASMs with their daily doses were assessed for the descriptive analysis. The quality of life was assessed in randomly selected PWE (n = 100) using the quality of life in epilepsy inventory-31 (QOLIE-31) in adults. Results With a total of 486 PWE, the median age (years) was comparable in both groups. Out of these the non-responders group was found to be significantly higher (77.8%) than the responders group (22.2%). In the responders group, the percentage of PWE who were on monotherapy was significantly higher (51.85 %) than those who were on polytherapy (17.59%), whereas in the non-responders group, 21.16% of PWE were on monotherapy and 44.86% were on polytherapy. The duration of epilepsy was similar in both groups, but the average seizure frequency was significantly higher in the non-responders. In QOL assessments, 43% of PWE were observed in the responders group, whereas 57% of PWE were found in the non-responders group. The overall comparative QOL scores were also significantly higher (p < 0.0001) in the responders group as compared to the non-responders group. Conclusion Our findings revealed that those PWE who were on monotherapy showed better reduction in seizure frequency and improved QOL in responder groups as compared to non-responder groups.
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Affiliation(s)
- Rekha Dwivedi
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Prabhakar Tiwari
- Department of Anatomy, All India Institute of Medical Sciences, New Delhi, 110029, India,Corresponding authors.
| | - Monika Pahuja
- Division of Biomedical Sciences, Indian Council of Medical Research
| | - Rima Dada
- Department of Anatomy, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Manjari Tripathi
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, 110029, India,Corresponding authors.
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Shi X, Wang Y, Zhang Y, Song C, Jiang Y, Zhao J, Xia L, Ma L, Jiang W. Effects of antiepileptic drugs polytherapy on pregnancy outcomes in women with epilepsy: An observation study in northwest China. Epilepsy Behav 2022; 135:108904. [PMID: 36095876 DOI: 10.1016/j.yebeh.2022.108904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/01/2022] [Accepted: 08/26/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The management of pregnant women with epilepsy (WWE) treated with antiepileptic drugs (AEDs) polytherapy poses a great challenge. The purpose of this study was to evaluate the major congenital malformations (MCMs) associated with AED polytherapy, to assess the impacts of polytherapy regimens on seizure control and breastfeeding, and to determine the potential predictors for pregnancy outcomes. METHODS This study was based on prospectively acquired data from a registry enrolling WWE in early pregnancy from Feb 2010 to July 2019, in which 123 pregnancies in 110 WWE were exposed to 27 different AED combinations. RESULTS There were 123 pregnancies in 110 WWE analyzed in our study. The live birth rate was 86.2 % and the risk of MCMs was 10.4 %. Multivariate analysis indicated that prenatal exposure to phenobarbital (odds ratio [OR], 17.424; 95 %CI, 1.510-201.067; P = 0.022) and topiramate (OR, 9.469; 95 %CI, 1.149-62.402; P = 0.036) was associated with increased risk of MCMs. Valproate (OR, 4.441; 95 %CI, 1.165-16.934; P = 0.029), phenobarbital (OR, 13.636; 95 %CI, 2.146-86.660; P = 0.006) and topiramate (OR, 7.527; 95 %CI, 1.764-32.118; P = 0.006) were significantly correlated with adverse pregnancy outcomes. Among 67 pregnancies in four combinations over 10 patients, 15 (22.4 %) remained seizure free through pregnancy, seizure frequency increased in 17 (25.4 %), decreased in 24 (35.8 %) women, in 26 (38.8 %) remained unchanged. Only 23.6 % of mothers undertook exclusive breastfeeding. Planned pregnancy was the only independent factor significantly associated with decreased risk of adverse pregnancy outcomes (OR, 0.139; 95 % CI, 0.051-0.382; P < 0.001). Notably, no adverse pregnancy outcome was recorded in pregnancies exposed to the combination of lamotrigine plus levetiracetam. CONCLUSION Prenatal exposure to the combinations containing valproate, phenobarbital, or topiramate was associated with increased risk of adverse pregnant outcomes. AED-related teratogenicity may be reduced by planned pregnancy in WWE exposed to polytherapy. Our findings also suggest the combination of lamotrigine and levetiracetam seems to be most desirable to balance seizure control and fetal safety.
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Affiliation(s)
- Xiaojing Shi
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Yuanyuan Wang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Yaoyao Zhang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Changgeng Song
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Yongli Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Jingjing Zhao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Liang Xia
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Lei Ma
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
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Lalatović S, Milovanović M, Krstić N. Stigma and its association with health-related quality of life in adults with epilepsy. Epilepsy Behav 2022; 135:108874. [PMID: 35973375 DOI: 10.1016/j.yebeh.2022.108874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/15/2022] [Accepted: 08/03/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To explore the presence of felt and enacted stigma in people with epilepsy (PWE), members of a self-governing epilepsy organization and to evaluate the influence of both types of stigma on health-related quality of life (HRQoL) in PWE. METHODS Participants were 55 PWE (age range: 18-53 years), members of a non-governmental organization (further "NGO"). The sociodemographic and epilepsy-related variables were collected through structured interviews designed for the purpose of the study. Felt stigma was assessed with the Epilepsy Stigma Scale (ESS) and enacted stigma with the Questionnaire for episodes of discrimination against PWE. Quality of Life in Epilepsy Inventory (QOLIE-31) (Serbian version) was used for the evaluation of HRQoL. RESULTS The mean ESS score was 33.93 ± 14.50. Felt stigma was significantly associated with the male gender and the number of antiepileptic drugs (AEDs). Participants' mean score on the Questionnaire for episodes of discrimination was 2.80 ± 2.78. Enacted stigma was significantly correlated with male gender and number of AEDs, as well as with older age/longer duration of the disorder. Felt stigma scores were positively correlated with enacted stigma scores (p < 0.001), but only felt stigma scores were negatively related to QOLIE-31 overall score (p = 0.01). The combination of AEDs, seizure frequency, and felt stigma best explained the HRQoL in PWE (p < 0.001). CONCLUSION Felt and enacted stigma are moderately related, but only felt stigma appears to be a significant predictor of the deteriorating HRQoL in this sample. Interventions targeting felt stigma should be considered a part of comprehensive epilepsy care as well as educating the wider community about epilepsy.
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Affiliation(s)
- Staša Lalatović
- Faculty of Special Education and Rehabilitation, University of Belgrade, Visokog Stevana 2, 11000 Belgrade, Serbia.
| | - Maja Milovanović
- Faculty of Special Education and Rehabilitation, University of Belgrade, Visokog Stevana 2, 11000 Belgrade, Serbia; Department for Epilepsy and Clinical Neurophysiology, Institute of Mental Health, Milana Kašanina 3, 11000 Belgrade, Serbia.
| | - Nadežda Krstić
- Faculty of Special Education and Rehabilitation, University of Belgrade, Visokog Stevana 2, 11000 Belgrade, Serbia.
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Hakeem H, Feng W, Chen Z, Choong J, Brodie MJ, Fong SL, Lim KS, Wu J, Wang X, Lawn N, Ni G, Gao X, Luo M, Chen Z, Ge Z, Kwan P. Development and Validation of a Deep Learning Model for Predicting Treatment Response in Patients With Newly Diagnosed Epilepsy. JAMA Neurol 2022; 79:986-996. [PMID: 36036923 PMCID: PMC9425285 DOI: 10.1001/jamaneurol.2022.2514] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 06/17/2022] [Indexed: 11/14/2022]
Abstract
Importance Selection of antiseizure medications (ASMs) for epilepsy remains largely a trial-and-error approach. Under this approach, many patients have to endure sequential trials of ineffective treatments until the "right drugs" are prescribed. Objective To develop and validate a deep learning model using readily available clinical information to predict treatment success with the first ASM for individual patients. Design, Setting, and Participants This cohort study developed and validated a prognostic model. Patients were treated between 1982 and 2020. All patients were followed up for a minimum of 1 year or until failure of the first ASM. A total of 2404 adults with epilepsy newly treated at specialist clinics in Scotland, Malaysia, Australia, and China between 1982 and 2020 were considered for inclusion, of whom 606 (25.2%) were excluded from the final cohort because of missing information in 1 or more variables. Exposures One of 7 antiseizure medications. Main Outcomes and Measures With the use of the transformer model architecture on 16 clinical factors and ASM information, this cohort study first pooled all cohorts for model training and testing. The model was trained again using the largest cohort and externally validated on the other 4 cohorts. The area under the receiver operating characteristic curve (AUROC), weighted balanced accuracy, sensitivity, and specificity of the model were all assessed for predicting treatment success based on the optimal probability cutoff. Treatment success was defined as complete seizure freedom for the first year of treatment while taking the first ASM. Performance of the transformer model was compared with other machine learning models. Results The final pooled cohort included 1798 adults (54.5% female; median age, 34 years [IQR, 24-50 years]). The transformer model that was trained using the pooled cohort had an AUROC of 0.65 (95% CI, 0.63-0.67) and a weighted balanced accuracy of 0.62 (95% CI, 0.60-0.64) on the test set. The model that was trained using the largest cohort only had AUROCs ranging from 0.52 to 0.60 and a weighted balanced accuracy ranging from 0.51 to 0.62 in the external validation cohorts. Number of pretreatment seizures, presence of psychiatric disorders, electroencephalography, and brain imaging findings were the most important clinical variables for predicted outcomes in both models. The transformer model that was developed using the pooled cohort outperformed 2 of the 5 other models tested in terms of AUROC. Conclusions and Relevance In this cohort study, a deep learning model showed the feasibility of personalized prediction of response to ASMs based on clinical information. With improvement of performance, such as by incorporating genetic and imaging data, this model may potentially assist clinicians in selecting the right drug at the first trial.
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Affiliation(s)
- Haris Hakeem
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Wei Feng
- Department of Electrical and Computer Systems Engineering, Monash University, Clayton, Victoria, Australia
- Monash-Airdoc Research, Monash University, Melbourne, Victoria, Australia
| | - Zhibin Chen
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Jiun Choong
- Department of Electrical and Computer Systems Engineering, Monash University, Clayton, Victoria, Australia
| | - Martin J. Brodie
- Department of Medicine and Clinical Pharmacology, University of Glasgow, Glasgow, Scotland
| | - Si-Lei Fong
- Neurology Division, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kheng-Seang Lim
- Neurology Division, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Junhong Wu
- Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China
| | - Xuefeng Wang
- Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China
| | - Nicholas Lawn
- WA Adult Epilepsy Service, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Guanzhong Ni
- Department of Neurology, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xiang Gao
- Department of Pharmacy, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Mijuan Luo
- Department of Pharmacy, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Ziyi Chen
- Department of Neurology, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Zongyuan Ge
- Department of Electrical and Computer Systems Engineering, Monash University, Clayton, Victoria, Australia
- Monash-Airdoc Research, Monash University, Melbourne, Victoria, Australia
- Monash eResearch Centre, Monash University, Melbourne, Victoria, Australia
| | - Patrick Kwan
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
- Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China
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Hyder Pottoo F, Salahuddin M, Khan FA, Albaqshi BT, Gomaa MS, Abdulla FS, AlHajri N, Alomary MN. Trio-Drug Combination of Sodium Valproate, Baclofen and Thymoquinone Exhibits Synergistic Anticonvulsant Effects in Rats and Neuro-Protective Effects in HEK-293 Cells. Curr Issues Mol Biol 2022; 44:4350-4366. [PMID: 36286014 PMCID: PMC9601194 DOI: 10.3390/cimb44100299] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 09/12/2022] [Accepted: 09/15/2022] [Indexed: 10/04/2023] Open
Abstract
Epilepsy is a chronic brain disorder, with anti-epileptic drugs (AEDs) providing relief from hyper-excitability of neurons, but largely failing to restrain neurodegeneration. We investigated a progressive preclinical trial in rats, whereby the test drugs; sodium valproate (SVP; 150 and 300 mg/kg), baclofen (BFN; 5 and 10 mg/kg), and thymoquinone (THQ; 40 and 80 mg/kg) were administered (i.p, once/day for 15 days) alone, and as low dose combinations, and subsequently tested for antiseizure and neuroprotective potential using electrical stimulation of neurons by Maximal electroshock (MES). The seizure stages were monitored, and hippocampal levels of m-TOR, IL-1β, IL-6 were measured. Hippocampal histopathology was also performed. Invitro and Insilco studies were run to counter-confirm the results from rodent studies. We report the synergistic effect of trio-drug combination; SVP (150 mg/kg), BFN (5 mg/kg) and THQ (40 mg/kg) against generalized seizures. The Insilco results revealed that trio-drug combination binds the Akt active site as a supramolecular complex, which could have served as a delivery system that affects the penetration and the binding to the new target. The potential energy of the ternary complex in the Akt active site after dynamics simulation was found to be -370.426 Kcal/mol, while the supramolecular ternary complex alone was -38.732 Kcal/mol, with a potential energy difference of -331.694 Kcal/mol, which favors the supramolecular ternary complex at Akt active site binding. In addition, the said combination increased cell viability by 267% and reduced morphological changes induced by Pentylenetetrazol (PTZ) in HEK-293 cells, which indicates the neuroprotective property of said combination. To conclude, we are the first to report the anti-convulsant and neuroprotective potential of the trio-drug combination.
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Affiliation(s)
- Faheem Hyder Pottoo
- Department of Pharmacology, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University, P.O. Box 1982, Dammam 31441, Saudi Arabia
| | - Mohammed Salahuddin
- Department of Clinical Pharmacy Research, Institute for Research and Medical Consultation, Imam Abdulrahman Bin Faisal University, P.O. Box 1982, Dammam 31441, Saudi Arabia
| | - Firdos Alam Khan
- Department of Stem Cell Research, Institute for Research and Medical Consultation, Imam Abdulrahman Bin Faisal University, P.O. Box 1982, Dammam 31441, Saudi Arabia
| | - Batool Taleb Albaqshi
- Department of Pharmacology, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University, P.O. Box 1982, Dammam 31441, Saudi Arabia
| | - Mohamed S. Gomaa
- Department of Pharmaceutical Chemistry, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University, P.O. Box 1982, Dammam 31441, Saudi Arabia
| | - Fatima S. Abdulla
- College of Medicine and Health Science, Khalifa University, Abu Dhabi P.O. Box 127788, United Arab Emirates
| | - Noora AlHajri
- Department of Medicine, Sheikh Shakhbout Medical City (SSMC), Abu Dhabi P.O. Box 127788, United Arab Emirates
| | - Mohammad N. Alomary
- National Centre for Biotechnology, Kind Abdulaziz City for Science and Technology (KACST), Riyadh 11442, Saudi Arabia
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van der Meer PB, Dirven L, Fiocco M, Vos MJ, Kouwenhoven MCM, van den Bent MJ, Taphoorn MJB, Koekkoek JAF. Effectiveness of Antiseizure Medication Duotherapies in Patients With Glioma: A Multicenter Observational Cohort Study. Neurology 2022; 99:e999-e1008. [PMID: 36219797 PMCID: PMC9519253 DOI: 10.1212/wnl.0000000000200807] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 04/12/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVES About 30% of patients with glioma need an add-on antiseizure medication (ASM) due to uncontrolled seizures on ASM monotherapy. This study aimed to determine whether levetiracetam combined with valproic acid (LEV + VPA), a commonly prescribed duotherapy, is more effective than other duotherapy combinations including either LEV or VPA in patients with glioma. METHODS In this multicenter retrospective observational cohort study, treatment failure (i.e., replacement by, addition of, or withdrawal of an ASM) for any reason was the primary outcome. Secondary outcomes included (1) treatment failure due to uncontrolled seizures and (2) treatment failure due to adverse effects. Time to treatment failure was estimated from the moment of ASM duotherapy initiation. Multivariable cause-specific Cox proportional hazard models were estimated to study the association between risk factors and treatment failure. The maximum duration of follow-up was 36 months. RESULTS A total of 1,435 patients were treated with first-line monotherapy LEV or VPA, of which 355 patients received ASM duotherapy after they had treatment failure due to uncontrolled seizures on monotherapy. LEV + VPA was prescribed in 66% (236/355) and other ASM duotherapy combinations including LEV or VPA in 34% (119/355) of patients. Patients using other duotherapy vs LEV + VPA had a higher risk of treatment failure for any reason (cause-specific adjusted hazard ratio [aHR] 1.50 [95% CI 1.07-2.12], p = 0.020), due to uncontrolled seizures (cause-specific aHR 1.73 [95% CI 1.10-2.73], p = 0.018), but not due to adverse effects (cause-specific aHR 0.88 [95% CI 0.47-1.67], p = 0.703). DISCUSSION This observational cohort study suggests that LEV + VPA has better efficacy than other ASM combinations. Similar toxicities were experienced in the 2 groups. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that for patients with glioma with uncontrolled seizures on ASM monotherapy, LEV + VPA has better efficacy than other ASM combinations.
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Affiliation(s)
- Pim B van der Meer
- From the Department of Neurology (P.M., L.D., M.J.B.T., J.A.F.K.), Leiden University Medical Center; Department of Neurology (L.D., M.J.V., M.J.B.T., J.A.F.K.), Haaglanden Medical Center, The Hague; Department of Biomedical Data Sciences (M.F.), Medical Statistics, Leiden University Medical Center; Mathematical Institute (M.F.), Leiden University; Department of Neurology (M.C.M.K.), Amsterdam University Medical Centers, location VUmc; and Brain Tumor Center at Erasmus Medical Center Cancer Institute (M.J.B.), Rotterdam, the Netherlands.
| | - Linda Dirven
- From the Department of Neurology (P.M., L.D., M.J.B.T., J.A.F.K.), Leiden University Medical Center; Department of Neurology (L.D., M.J.V., M.J.B.T., J.A.F.K.), Haaglanden Medical Center, The Hague; Department of Biomedical Data Sciences (M.F.), Medical Statistics, Leiden University Medical Center; Mathematical Institute (M.F.), Leiden University; Department of Neurology (M.C.M.K.), Amsterdam University Medical Centers, location VUmc; and Brain Tumor Center at Erasmus Medical Center Cancer Institute (M.J.B.), Rotterdam, the Netherlands
| | - Marta Fiocco
- From the Department of Neurology (P.M., L.D., M.J.B.T., J.A.F.K.), Leiden University Medical Center; Department of Neurology (L.D., M.J.V., M.J.B.T., J.A.F.K.), Haaglanden Medical Center, The Hague; Department of Biomedical Data Sciences (M.F.), Medical Statistics, Leiden University Medical Center; Mathematical Institute (M.F.), Leiden University; Department of Neurology (M.C.M.K.), Amsterdam University Medical Centers, location VUmc; and Brain Tumor Center at Erasmus Medical Center Cancer Institute (M.J.B.), Rotterdam, the Netherlands
| | - Maaike J Vos
- From the Department of Neurology (P.M., L.D., M.J.B.T., J.A.F.K.), Leiden University Medical Center; Department of Neurology (L.D., M.J.V., M.J.B.T., J.A.F.K.), Haaglanden Medical Center, The Hague; Department of Biomedical Data Sciences (M.F.), Medical Statistics, Leiden University Medical Center; Mathematical Institute (M.F.), Leiden University; Department of Neurology (M.C.M.K.), Amsterdam University Medical Centers, location VUmc; and Brain Tumor Center at Erasmus Medical Center Cancer Institute (M.J.B.), Rotterdam, the Netherlands
| | - Mathilde C M Kouwenhoven
- From the Department of Neurology (P.M., L.D., M.J.B.T., J.A.F.K.), Leiden University Medical Center; Department of Neurology (L.D., M.J.V., M.J.B.T., J.A.F.K.), Haaglanden Medical Center, The Hague; Department of Biomedical Data Sciences (M.F.), Medical Statistics, Leiden University Medical Center; Mathematical Institute (M.F.), Leiden University; Department of Neurology (M.C.M.K.), Amsterdam University Medical Centers, location VUmc; and Brain Tumor Center at Erasmus Medical Center Cancer Institute (M.J.B.), Rotterdam, the Netherlands
| | - Martin J van den Bent
- From the Department of Neurology (P.M., L.D., M.J.B.T., J.A.F.K.), Leiden University Medical Center; Department of Neurology (L.D., M.J.V., M.J.B.T., J.A.F.K.), Haaglanden Medical Center, The Hague; Department of Biomedical Data Sciences (M.F.), Medical Statistics, Leiden University Medical Center; Mathematical Institute (M.F.), Leiden University; Department of Neurology (M.C.M.K.), Amsterdam University Medical Centers, location VUmc; and Brain Tumor Center at Erasmus Medical Center Cancer Institute (M.J.B.), Rotterdam, the Netherlands
| | - Martin J B Taphoorn
- From the Department of Neurology (P.M., L.D., M.J.B.T., J.A.F.K.), Leiden University Medical Center; Department of Neurology (L.D., M.J.V., M.J.B.T., J.A.F.K.), Haaglanden Medical Center, The Hague; Department of Biomedical Data Sciences (M.F.), Medical Statistics, Leiden University Medical Center; Mathematical Institute (M.F.), Leiden University; Department of Neurology (M.C.M.K.), Amsterdam University Medical Centers, location VUmc; and Brain Tumor Center at Erasmus Medical Center Cancer Institute (M.J.B.), Rotterdam, the Netherlands
| | - Johan A F Koekkoek
- From the Department of Neurology (P.M., L.D., M.J.B.T., J.A.F.K.), Leiden University Medical Center; Department of Neurology (L.D., M.J.V., M.J.B.T., J.A.F.K.), Haaglanden Medical Center, The Hague; Department of Biomedical Data Sciences (M.F.), Medical Statistics, Leiden University Medical Center; Mathematical Institute (M.F.), Leiden University; Department of Neurology (M.C.M.K.), Amsterdam University Medical Centers, location VUmc; and Brain Tumor Center at Erasmus Medical Center Cancer Institute (M.J.B.), Rotterdam, the Netherlands
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13
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Smith MC, Klein P, Krauss GL, Rashid S, Seiden LG, Stern JM, Rosenfeld WE. Dose Adjustment of Concomitant Antiseizure Medications During Cenobamate Treatment: Expert Opinion Consensus Recommendations. Neurol Ther 2022; 11:1705-1720. [PMID: 36057761 PMCID: PMC9588096 DOI: 10.1007/s40120-022-00400-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/15/2022] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Our objective was to provide expert consensus recommendations to improve treatment tolerability through dose adjustments of concomitant antiseizure medications (ASMs) during addition of cenobamate to existing ASM therapy in adult patients with uncontrolled focal seizures. METHODS A panel of seven epileptologists experienced in the use of ASMs, including cenobamate, used a modified Delphi process to reach consensus. The panelists discussed tolerability issues with concomitant ASMs during cenobamate titration and practical strategies for dose adjustments that may prevent or mitigate adverse effects. The resulting recommendations consider concomitant ASM dose level and specify proactive (prior to report of an adverse effect) and reactive (in response to report of an adverse effect) dose adjustment suggestions based on concomitant ASM pharmacokinetic and pharmacodynamic interactions with cenobamate. Specific dose adjustment recommendations are provided. RESULTS We recommend proactively lowering the dose of clobazam, phenytoin, and phenobarbital due to their known drug-drug interactions with cenobamate, and lacosamide due to a pharmacodynamic interaction with cenobamate, to prevent adverse effects during cenobamate titration. Reactive lowering of a concomitant ASM dose is sufficient for other ASMs at standard dosing owing to quick resolution of adverse effects. For carbamazepine and lamotrigine doses exceeding the upper end of standard dosing (e.g., carbamazepine, greater than 1200 mg/day; lamotrigine, greater than 500 mg/day), we encourage consideration of proactive dose reduction at cenobamate 200 mg/day to prevent potential adverse effects. All dose reductions for adverse effects can be repeated every 2 weeks as dictated by the adverse effects. At cenobamate 200 mg/day, we recommend that patients be evaluated for marked improvement of seizures and further dose reductions be considered to reduce potentially unnecessary polypharmacy. CONCLUSION The primary goal of the recommended dose reductions of concomitant ASMs is to prevent or resolve adverse effects, thereby allowing cenobamate to reach the optimal dose to achieve the maximal potential of improving seizure control.
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Affiliation(s)
- Michael C. Smith
- Department of Neurological Sciences, Section of Clinical Neurophysiology and Epilepsy, Rush Medical College, 1725 W. Harrison Street, Suite 885, Chicago, IL 60612 USA
| | - Pavel Klein
- Mid-Atlantic Epilepsy and Sleep Center, Bethesda, MD USA
| | | | - Samiya Rashid
- Epilepsy and Neurology Specialists of San Diego, Encinitas, CA USA
| | | | - John M. Stern
- University of California at Los Angeles, Los Angeles, CA USA
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Connor GS, Williamson A. Effectiveness and safety of adjunctive cenobamate for focal seizures in adults with developmental disability treated in clinical practice. Epilepsy Behav Rep 2022; 18:100533. [PMID: 35345772 PMCID: PMC8956884 DOI: 10.1016/j.ebr.2022.100533] [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: 01/10/2022] [Revised: 03/03/2022] [Accepted: 03/04/2022] [Indexed: 11/16/2022] Open
Abstract
92.9% (26/28 patients) continued cenobamate through 6 months, showing high retention. High responder rates/substantial focal seizure reduction occurred with cenobamate. 100% seizure reduction occurred in 48.2% of patients at 6 months. Adverse effects were often mitigated by concomitant antiseizure medication reduction.
Effectiveness and tolerability of adjunctive cenobamate for uncontrolled focal seizures in adults living with a developmental disability are not defined. Retrospective medical record review included adults ≥18 years old living with a developmental disability, either in a group home or with parents, and experiencing uncontrolled focal seizures despite stable doses of ≥1 antiseizure medication (ASM). Effectiveness was examined as percentage change in focal seizure frequency per month from the 2-month average before cenobamate to the average of months 5 and 6 while receiving cenobamate. Percentages of patients achieving responder rates in focal seizure frequency at 6 months of cenobamate treatment were examined. Adverse effects and concomitant ASM dosage adjustments were assessed. Of the 28 included patients, 26 (92.9%) continued cenobamate beyond 6 months. The responder rate of 100% seizure reduction (seizure-free) occurred in 48.2% of the patients who continued cenobamate for 6 months. Ten adverse effects were reported in 9 patients (32.1%), and 80% (8/10) were resolved by reducing concomitant ASM dosages. Two patients (7.1%) discontinued cenobamate due to adverse effects. Cenobamate resulted in substantial reduction in focal seizure frequency and was well tolerated.
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Affiliation(s)
- Gregory S. Connor
- Neurological Center of Oklahoma, 6585 South Yale Avenue, Suite 620, Tulsa, OK 74136, United States
- Corresponding author at: Neurological Center of Oklahoma, PLC, 6585 South Yale Avenue, Suite 620, Tulsa, OK 74136, United States.
| | - Amanda Williamson
- SK Life Science, Inc., 461 From Road, Fifth Floor, Paramus, NJ 07652, United States
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Rosenfeld WE, Abou-Khalil B, Aboumatar S, Bhatia P, Biton V, Krauss GL, Sperling MR, Vossler DG, Klein P, Wechsler R. Post hoc analysis of a phase 3, multicenter, open-label study of cenobamate for treatment of uncontrolled focal seizures: Effects of dose adjustments of concomitant antiseizure medications. Epilepsia 2021; 62:3016-3028. [PMID: 34633074 PMCID: PMC9292883 DOI: 10.1111/epi.17092] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/23/2021] [Accepted: 09/23/2021] [Indexed: 01/23/2023]
Abstract
Objective To report post hoc results on how adjustments to baseline antiseizure medications (ASMs) in a subset of study sites (10 US sites) from a long‐term, open‐label phase 3 study of adjunctive cenobamate affected tolerability, efficacy, and retention. Methods Patients with uncontrolled focal seizures taking stable doses of one to three ASMs were administered increasing doses of cenobamate (12.5, 25, 50, 100, 150, 200 mg/day) over 12 weeks at 2‐week intervals (target dose = 200 mg/day). Further increases to 400 mg/day by 50 mg/day biweekly increments were allowed during maintenance phase. Dose adjustments of cenobamate and concomitant ASMs were allowed. Data were assessed until last visit, at data cut‐off, on or after September 1, 2019. Results A total of 240 patients meeting eligibility criteria were assessed (median [max] exposure 30.2 [43.0] months), with 177 patients continuing cenobamate at data cut‐off. Most common baseline concomitant ASMs were lacosamide, levetiracetam, lamotrigine, zonisamide, and clobazam. For most baseline concomitant ASMs, ~70% of patients taking that ASM were continuing cenobamate at data cut‐off. Patients continuing cenobamate had greater mean ASM dose reductions and percent dose changes from baseline vs those who discontinued. Of patients continuing cenobamate, 24.6% discontinued one or more concomitant ASMs completely. Dose decreases for all concomitant ASMs generally occurred during titration or early maintenance phases and were mostly due to central nervous system (CNS)–related adverse events such as somnolence, dizziness, unsteady gait, and fatigue. Responder rates from ≥50% through 100% for patients continuing cenobamate were generally similar regardless of concomitant ASMs (of those most commonly taken), with ~81% being ≥50% responders and ~12% achieving 100% seizure reduction in the maintenance phase, which lasted up to 40.2 (median = 29.5) months. Significance Concomitant ASM dose reductions were associated with more patients remaining on cenobamate. This is likely due to efficacy and improved tolerability, with overall reduced concomitant drug burden in patients with uncontrolled seizures despite taking one to three baseline concomitant ASMs.
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Affiliation(s)
- William E Rosenfeld
- Comprehensive Epilepsy Care Center for Children and Adults, St. Louis, Missouri, USA
| | | | | | | | - Victor Biton
- Arkansas Epilepsy Program, Little Rock, Arkansas, USA
| | - Gregory L Krauss
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - David G Vossler
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Pavel Klein
- Mid-Atlantic Epilepsy and Sleep Center, Bethesda, Maryland, USA
| | - Robert Wechsler
- Consultants in Epilepsy & Neurology, PLLC, Boise, Idaho, USA.,Idaho Comprehensive Epilepsy Center, Boise, Idaho, USA
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Serafini R. How much can medical management alone improve the outcome of adult drug-resistant epilepsy? An exploratory study on possibilities and limitations of combining multiple therapeutic actions. Epilepsy Behav 2021; 122:108065. [PMID: 34243142 DOI: 10.1016/j.yebeh.2021.108065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 05/03/2021] [Accepted: 05/08/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE Failure to control epileptic seizures with two medications, adequately chosen and dosed, indicates drug-resistant epilepsy (DRE). The chance of pharmacologically controlling seizures is low for patients with DRE and uncontrolled seizures who are not candidates for surgery, who have already undergone surgery, or who already had a vagus nerve stimulator (VNS) placed. Patients experiencing these conditions must instead rely on medical management of their seizures, and there is no breakthrough solution on the horizon. Medical care of DRE might be optimized by systematically considering factors that promote and inhibit breakthrough seizures. For example, seizure control could be enhanced through measures such as increasing the frequency of follow-up visits, tracking treatment plan compliance, treating sleep disorders, rational polypharmacy, adjusting drug administration to achieve higher levels when seizures are more likely and educating patients on seizure triggers. A systematic and simultaneous implementation of all of these measures is likely to yield a sizable, clinically relevant, improvement. This paper presents an exploratory study on the effects of implementing such an approach, specifically evaluating this method's impact on seizure frequency. METHODS I performed a retrospective chart review of 659 consecutive adult patients with epilepsy followed up at the University of Utah and at the Salt Lake City VA Medical center using the multimodal approach described above. I identified 27 patients who had DRE and uncontrolled seizures and in whom a medical management optimization protocol was implemented. I measured these patients' seizure frequency at the beginning and the end of the study period and compared the results with those of a matching control group of 48 patients. RESULTS The optimization protocol did not increase the number of seizure-free patients with DRE; however, it was effective in minimizing seizure frequency in patients whose seizures remained uncontrolled. Among these patients, the median seizure frequency dropped by 64% in the optimization group but did not change in the control group. CONCLUSIONS Despite the high occurrence of DRE, there is no accepted protocol for the related medical management. This paper describes an effective approach that can be implemented in a clinically relevant and readily achievable manner.
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Affiliation(s)
- Ruggero Serafini
- Department of Neurology, University of Utah Clinical Neuroscience Center, George E. Wahlen VA Medical Center, 175 North Medical Drive East, 5th Floor, Salt Lake City, UT 84132, USA.
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Łukawski K, Czuczwar SJ. Understanding mechanisms of drug resistance in epilepsy and strategies for overcoming it. Expert Opin Drug Metab Toxicol 2021; 17:1075-1090. [PMID: 34310255 DOI: 10.1080/17425255.2021.1959912] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The present evidence indicates that approximately 70% of patients with epilepsy can be successfully treated with antiepileptic drugs (AEDs). A significant proportion of patients are not under sufficient control, and pharmacoresistant epilepsy is clearly associated with poor quality of life and increased morbidity and mortality. There is a great need for newer therapeutic options able to reduce the percentage of drug-resistant patients. AREAS COVERED A number of hypotheses trying to explain the development of pharmacoresistance have been put forward. These include: target hypothesis (altered AED targets), transporter (overexpression of brain efflux transporters), pharmacokinetic (overexpression of peripheral efflux transporters in the intestine or kidneys), intrinsic severity (initial high seizure frequency), neural network (aberrant networks), and gene variant hypothesis (genetic polymorphisms). EXPERT OPINION A continuous search for newer AEDs or among non-AEDs (blockers of efflux transporters, interleukin antagonists, cyclooxygenase inhibitors, mTOR inhibitors, angiotensin II receptor antagonists) may provide efficacious drugs for the management of drug-resistant epilepsy. Also, combinations of AEDs exerting synergy in preclinical and clinical studies (for instance, lamotrigine + valproate, levetiracetam + valproate, topiramate + carbamazepine) might be of importance in this respect. Preclinically antagonistic combinations must be avoided (lamotrigine + carbamazepine, lamotrigine + oxcarbazepine).
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Affiliation(s)
- Krzysztof Łukawski
- Department of Physiopathology, Institute of Rural Health, Lublin, Poland.,Department of Pathophysiology, Medical University of Lublin, Lublin, Poland
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Masumshah R, Aghdam R, Eslahchi C. A neural network-based method for polypharmacy side effects prediction. BMC Bioinformatics 2021; 22:385. [PMID: 34303360 PMCID: PMC8305591 DOI: 10.1186/s12859-021-04298-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Polypharmacy is a type of treatment that involves the concurrent use of multiple medications. Drugs may interact when they are used simultaneously. So, understanding and mitigating polypharmacy side effects are critical for patient safety and health. Since the known polypharmacy side effects are rare and they are not detected in clinical trials, computational methods are developed to model polypharmacy side effects. RESULTS We propose a neural network-based method for polypharmacy side effects prediction (NNPS) by using novel feature vectors based on mono side effects, and drug-protein interaction information. The proposed method is fast and efficient which allows the investigation of large numbers of polypharmacy side effects. Our novelty is defining new feature vectors for drugs and combining them with a neural network architecture to apply for the context of polypharmacy side effects prediction. We compare NNPS on a benchmark dataset to predict 964 polypharmacy side effects against 5 well-established methods and show that NNPS achieves better results than the results of all 5 methods in terms of accuracy, complexity, and running time speed. NNPS outperforms about 9.2% in Area Under the Receiver-Operating Characteristic, 12.8% in Area Under the Precision-Recall Curve, 8.6% in F-score, 10.3% in Accuracy, and 18.7% in Matthews Correlation Coefficient with 5-fold cross-validation against the best algorithm among other well-established methods (Decagon method). Also, the running time of the Decagon method which is 15 days for one fold of cross-validation is reduced to 8 h by the NNPS method. CONCLUSIONS The performance of NNPS is benchmarked against 5 well-known methods, Decagon, Concatenated drug features, Deep Walk, DEDICOM, and RESCAL, for 964 polypharmacy side effects. We adopt the 5-fold cross-validation for 50 iterations and use the average of the results to assess the performance of the NNPS method. The evaluation of the NNPS against five well-known methods, in terms of accuracy, complexity, and running time speed shows the performance of the presented method for an essential and challenging problem in pharmacology. Datasets and code for NNPS algorithm are freely accessible at https://github.com/raziyehmasumshah/NNPS .
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Affiliation(s)
- Raziyeh Masumshah
- Department of Computer and Data Sciences, Faculty of Mathematical Sciences, Shahid Beheshti University, Tehran, Iran
| | - Rosa Aghdam
- School of Biological Sciences, Institute for Research in Fundamental Sciences (IPM), Tehran, Iran.
| | - Changiz Eslahchi
- Department of Computer and Data Sciences, Faculty of Mathematical Sciences, Shahid Beheshti University, Tehran, Iran.
- School of Biological Sciences, Institute for Research in Fundamental Sciences (IPM), Tehran, Iran.
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Alotaibi BS, Alodhayani AA, Alwan A, Alotaibi KN, Melaiki BT, Almadhi AM, Alfares LH, Alalkami NA. Detrimental effect of antiepileptic drugs dose in pediatric children with epilepsy in Saudi Arabia: A prospective cohort study. Medicine (Baltimore) 2021; 100:e26478. [PMID: 34190172 PMCID: PMC8257875 DOI: 10.1097/md.0000000000026478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 06/07/2021] [Indexed: 11/26/2022] Open
Abstract
This study aims to evaluate the effect of dose titration for different oral antiepileptic medications among children with epilepsy in Riyadh, Saudi Arabia.A single-center prospective pilot, cohort study was undertaken at a tertiary hospital in Riyadh, Saudi Arabia. All medical records of pediatric patients below the age of 14 years of age who has been newly diagnosed with epilepsy by attending a medical specialist or on a new epileptic treatment plans were enrolled in the study.A total of 76 epileptic patients were screened for 3 months' period and 48 patients were included in this study. Out of the 48 patients, 31 patients followed the regular practice in the titration processes and 17 patients were in the British national formulary (BNF) guideline. Fifteen children who were on monotherapy of levetiracetam were in regular practice guideline experienced poor seizure control with a recorded number of seizure incidence (n = 10). The patient in regular practice guidelines using a combination therapy of phenytoin and levetiracetam were experiencing some behavioral disturbance and sedation effect. Seventeen patients followed in the BNF guideline who were on levetiracetam were experienced less adverse effect (n = 2) with no behavioral changes.The group who followed the regular practice found having a greater incidence of documented adverse effects compared to the patients following the BNF guideline. The titrating antiepileptic medication has a detrimental effect on the pediatric population as observed in this study.
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Affiliation(s)
- Badriyah S. Alotaibi
- College of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Abdulaziz A. Alodhayani
- Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ashraf Alwan
- Department of Pharmaceutical Services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Khalid Nijr Alotaibi
- Pediatric Neurology, Prince Sultan Military Medical City, Department of Pharmaceutical Services, Riyadh, Saudi Arabia
| | - Brahim Tabarki Melaiki
- Pediatric Neurology, Prince Sultan Military Medical City, Department of Pharmaceutical Services, Riyadh, Saudi Arabia
| | - Aljawharah Mohammad Almadhi
- Pediatric Neurology, Prince Sultan Military Medical City, Department of Pharmaceutical Services, Riyadh, Saudi Arabia
| | - Lulwah Haitham Alfares
- Pediatric Neurology, Prince Sultan Military Medical City, Department of Pharmaceutical Services, Riyadh, Saudi Arabia
| | - Nahlah Ahmed Alalkami
- Pediatric Neurology, Prince Sultan Military Medical City, Department of Pharmaceutical Services, Riyadh, Saudi Arabia
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20
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Hersi H, Saarinen JT, Raitanen J, Peltola J. Response to first antiseizure medication in patients diagnosed with epilepsy. Acta Neurol Scand 2021; 144:67-75. [PMID: 33835491 DOI: 10.1111/ane.13426] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/22/2021] [Accepted: 03/23/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To investigate the interaction among the efficacy, tolerability and overall effectiveness of the first antiseizure medication in patients 16 years or older with newly diagnosed epilepsy. MATERIALS AND METHODS The study included 584 patients who were referred to the Tampere University Hospital between 1 January 1995 and 31 December 2005 and were diagnosed with epilepsy. All individuals were retrospectively followed up until 31 December 2006, until reaching at least one year of seizure freedom, or until death if before the cut-off date. RESULTS Overall, after thorough validation of the epilepsy diagnosis 459 patients comprised the study cohort; among these patients, 73% of males and 60% of females became seizure-free for at least one year with the first antiseizure medication. The seizure freedom rate for focal epilepsy was 67%. There was no significant difference in focal epilepsy to achieve seizure freedom between oxcarbazepine, carbamazepine or valproic acid. The seizure freedom rate among patients above 60 years of age was 67%. For patients with structural and unknown aetiology, seizure freedom rates were 61.5% and 75.3%, respectively. Additionally, epileptiform activity on EEG in patients with focal epilepsy decreased odds of seizure freedom in adjusted logistic regression models (OR 0.55, p=0.036). CONCLUSIONS This study provides a more positive prediction of seizure freedom compared with previous studies with the onset of epilepsy at 16 years or older with an overall estimation that two-thirds of patients with new-onset epilepsy obtain seizure freedom with the first antiseizure medication.
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Affiliation(s)
- Hire Hersi
- Department of Neurology Vaasa Central Hospital Vaasa Finland
| | | | - Jani Raitanen
- Faculty of Social Sciences Tampere University and UKK Institute for Health Promotion Research (J.R) Tampere Finland
| | - Jukka Peltola
- Department of Neurology (J.P) Tampere University Tampere Finland
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21
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Fattorusso A, Matricardi S, Mencaroni E, Dell'Isola GB, Di Cara G, Striano P, Verrotti A. The Pharmacoresistant Epilepsy: An Overview on Existent and New Emerging Therapies. Front Neurol 2021; 12:674483. [PMID: 34239494 PMCID: PMC8258148 DOI: 10.3389/fneur.2021.674483] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/27/2021] [Indexed: 12/21/2022] Open
Abstract
Epilepsy is one of the most common neurological chronic disorders, with an estimated prevalence of 0. 5 - 1%. Currently, treatment options for epilepsy are predominantly based on the administration of symptomatic therapy. Most patients are able to achieve seizure freedom by the first two appropriate drug trials. Thus, patients who cannot reach a satisfactory response after that are defined as pharmacoresistant. However, despite the availability of more than 20 antiseizure medications (ASMs), about one-third of epilepsies remain drug-resistant. The heterogeneity of seizures and epilepsies, the coexistence of comorbidities, and the broad spectrum of efficacy, safety, and tolerability related to the ASMs, make the management of these patients actually challenging. In this review, we analyze the most relevant clinical and pathogenetic issues related to drug-resistant epilepsy, and then we discuss the current evidence about the use of available ASMs and the alternative non-pharmacological approaches.
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Affiliation(s)
- Antonella Fattorusso
- Department of Medicine and Surgery, Pediatric Clinic, University of Perugia, Perugia, Italy
| | - Sara Matricardi
- Child Neurology and Psychiatry Unit, Children's Hospital “G. Salesi”, Ospedali Riuniti Ancona, Ancona, Italy
| | - Elisabetta Mencaroni
- Department of Medicine and Surgery, Pediatric Clinic, University of Perugia, Perugia, Italy
| | | | - Giuseppe Di Cara
- Department of Medicine and Surgery, Pediatric Clinic, University of Perugia, Perugia, Italy
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, IRCCS “G. Gaslini” Institute, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Alberto Verrotti
- Department of Medicine and Surgery, Pediatric Clinic, University of Perugia, Perugia, Italy
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Mechanisms of Drug Resistance in the Pathogenesis of Epilepsy: Role of Neuroinflammation. A Literature Review. Brain Sci 2021; 11:brainsci11050663. [PMID: 34069567 PMCID: PMC8161227 DOI: 10.3390/brainsci11050663] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/13/2021] [Accepted: 05/17/2021] [Indexed: 12/16/2022] Open
Abstract
Epilepsy is a chronic neurological disorder characterized by recurring spontaneous seizures. Drug resistance appears in 30% of patients and it can lead to premature death, brain damage or a reduced quality of life. The purpose of the study was to analyze the drug resistance mechanisms, especially neuroinflammation, in the epileptogenesis. The information bases of biomedical literature Scopus, PubMed, Google Scholar and SciVerse were used. To obtain full-text documents, electronic resources of PubMed Central and Research Gate were used. The article examines the recent research of the mechanisms of drug resistance in epilepsy and discusses the hypotheses of drug resistance development (genetic, epigenetic, target hypothesis, etc.). Drug-resistant epilepsy is associated with neuroinflammatory, autoimmune and neurodegenerative processes. Neuroinflammation causes immune, pathophysiological, biochemical and psychological consequences. Focal or systemic unregulated inflammatory processes lead to the formation of aberrant neural connections and hyperexcitable neural networks. Inflammatory mediators affect the endothelium of cerebral vessels, destroy contacts between endothelial cells and induce abnormal angiogenesis (the formation of “leaky” vessels), thereby affecting the blood–brain barrier permeability. Thus, the analysis of pro-inflammatory and other components of epileptogenesis can contribute to the further development of the therapeutic treatment of drug-resistant epilepsy.
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Osuntokun OS, Babatunde AA, Olayiwola G, Atere TG, Oladokun OO, Adedokun KI. Assessment of the biomarkers of hepatotoxicity following carbamazepine, levetiracetam, and carbamazepine-levetiracetam adjunctive treatment in male Wistar rats. Toxicol Rep 2021; 8:592-598. [PMID: 33786324 PMCID: PMC7994541 DOI: 10.1016/j.toxrep.2021.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 02/27/2021] [Accepted: 03/06/2021] [Indexed: 11/15/2022] Open
Abstract
Objective This study examined some of the biomarkers of hepatotoxicity following chronic treatment with carbamazepine (CBZ), levetiracetam (LEV), and CBZ + LEV adjunctive treatment in male rats. Method Twenty-four male Wistar rats (140-150 g) were randomized into four groups (n = 6) to receive oral dose of normal saline (0.1 mL), CBZ (25 mg/kg), LEV (50 mg/kg) or sub-therapeutic dose of CBZ (12.5 mg/kg) together with LEV (25 mg/kg) for 28 days. Activities of the liver enzymes and oxidative stress markers were determined while liver histomorphology was also carried out. Data were analyzed using descriptive and inferential statistics. The results were presented as mean ± SEM in graphs or tables, while the level of significance was taken at p < 0.05. Results The activities of alkaline-phosphatase and malondialdehyde concentrations increased significantly in all the drug treatment groups, while the activities of superoxide dismutase decreased significantly following CBZ, and CBZ + LEV treatment. Alanine-aminotransferase activities increased significantly in the CBZ and CBZ + LEV treated rats compared with control. The liver section of CBZ treated rats showed mild vascular congestion. Conclusion None of these AEDs treatment is devoid of hepatotoxicity. However, the adverse effects in CBZ were greater than LEV, or CBZ + LEV adjunctive treatment.
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Affiliation(s)
- Opeyemi Samson Osuntokun
- Department of Physiology, Faculty of Basic Medical Sciences, College of Health Sciences, Osun State University Osogbo, Nigeria
| | - Ademola Adeniyi Babatunde
- Department of Physiology, Faculty of Basic Medical Sciences, College of Health Sciences, Osun State University Osogbo, Nigeria
| | - Gbola Olayiwola
- Department of Clinical Pharmacy and Pharmacy Administration, Faculty of Pharmacy, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Tope Gafar Atere
- Department of Medical Biochemistry, Faculty of Basic Medical Sciences, College of Health Sciences, Osun State University, Osogbo, Nigeria
| | - Olayemi Olutobi Oladokun
- Department of Physiology, Faculty of Basic Medical Sciences, College of Health Sciences, Osun State University Osogbo, Nigeria
| | - Kabiru Isola Adedokun
- Department of Physiology, Faculty of Basic Medical Sciences, College of Health Sciences, Osun State University Osogbo, Nigeria
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Łukawski K, Czuczwar SJ. Developing precision treatments for epilepsy using patient and animal models. Expert Rev Neurother 2020; 21:1241-1250. [PMID: 33339471 DOI: 10.1080/14737175.2021.1866989] [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] [Indexed: 10/22/2022]
Abstract
Introduction: Phenytoin was the first antiepileptic drug (AED) discovered in an animal model of seizures whose clinical efficacy was subsequently confirmed. This clearly indicated that a search for other AEDs had to consider animal studies.Areas covered: Main seizure tests used for the evaluation of possible anticonvulsive activity of potential anticonvulsants and their predictive values have been reviewed. Procedures used for the estimation of antiepileptogenic effects have been also included.Expert opinion: First-line seizure models comprise maximal electroshock (MES)-, pentylenetetrazol (PTZ)- and kindling-induced convulsions in rodents. The MES test may be considered as a convenient and easy model of generalized tonic-clonic seizures, PTZ test - as a model of generalized myoclonic seizures and to a certain degree - absence seizures. Kindled seizures (for example, from amygdala) may be regarded as a model of focal seizures. Some tests have been suggested for the search of AEDs effective in drug-resistant seizures - for instance, 6 Hz (44 mA) test or intrahippocampal kainate model of mesial temporal lobe epilepsy. There are also recommendations from experimental epileptology on synergistic AED combinations for patients with drug-resistant seizures. The clinical evidence on this issue is scarce and favors a combined treatment with valproate + lamotrigine.
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Affiliation(s)
- Krzysztof Łukawski
- Department of Physiopathology, Institute of Rural Health, Lublin, Poland.,Department of Pathophysiology, Medical University of Lublin, Lublin, Poland
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25
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Borowicz-Reutt KK, Czuczwar SJ, Rusek M. Interactions of antiepileptic drugs with drugs approved for the treatment of indications other than epilepsy. Expert Rev Clin Pharmacol 2020; 13:1329-1345. [PMID: 33305639 DOI: 10.1080/17512433.2020.1850258] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Introduction: Comorbidities of epilepsy may significantly interfere with its treatment as diseases in the general population are also encountered in epilepsy patients and some of them even more frequently (for instance, depression, anxiety, or heart disease). Obviously, some drugs approved for other than epilepsy indications can modify the anticonvulsant activity of antiepileptics. Areas covered: This review highlights the drug-drug interactions between antiepileptics and aminophylline, some antidepressant, antiarrhythmic (class I-IV), selected antihypertensive drugs and non-barbiturate injectable anesthetics (ketamine, propofol, etomidate, and alphaxalone). The data were reviewed mainly from experimental models of seizures. Whenever possible, clinical data were provided. PUBMED data base was the main search source.Expert opinion: Aminophylline generally reduced the protective activity of antiepileptics, which, to a certain degree, was consistent with scarce clinical data on methylxanthine derivatives and worse seizure control. The only antiarrhythmic with this profile of action was mexiletine when co-administered with VPA. Among antidepressants and non-barbiturate injectable anesthetics, trazodone, mianserin and etomidate or alphaxalone, respectively, negatively affected the anticonvulsant action of some antiepileptic drugs. Clinical data indicate that only amoxapine, bupropion, clomipramine and maprotiline should be used with caution. Possibly, drugs reducing the anticonvulsant potential of antiepileptics should be avoided in epilepsy patients.
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Affiliation(s)
- Kinga K Borowicz-Reutt
- Independent Unit of Experimental Neuropathophysiology, Department of Pathophysiology, Medical University of Lublin , Lublin, Poland
| | | | - Marta Rusek
- Department of Pathophysiology, Medical University of Lublin , Lublin, Poland.,Department of Dermatology, Venereology and Pediatric Dermatology, Laboratory for Immunology of Skin Diseases, Medical University of Lublin , Lublin, Poland
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26
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Janmohamed M, Lawn N, Spilsbury K, Chan J, Dunne J. Starting a new anti-seizure medication in drug-resistant epilepsy: Add-on or substitute? Epilepsia 2020; 62:228-237. [PMID: 33236785 DOI: 10.1111/epi.16765] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/01/2020] [Accepted: 11/02/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Randomized studies in drug-resistant epilepsy (DRE) typically involve addition of a new anti-seizure medication (ASM). However, in clinical practice, if the patient is already taking multiple ASMs, then substitution of one of the current ASMs commonly occurs, despite little evidence supporting this approach. METHODS Longitudinal prospective study of seizure outcome after commencing a previously untried ASM in patients with DRE. Multivariable time-to-event and logistic regression models were used to evaluate outcomes by whether the new ASM was introduced by addition or substitution. RESULTS A total of 816 ASM changes in 436 adult patients with DRE between 2010 and 2018 were analyzed. The new ASM was added on 407 (50.1%) occasions and substituted on 409 (49.9%). Mean patient follow-up was 3.2 years. Substitution was more likely if the new ASM was enzyme-inducing or in patients with a greater number of concurrent ASMs. ASM add-on was more likely if a γ-aminobutyric acid (GABA) agonist was introduced or if the patient had previously trialed a higher number of ASMs. The rate of discontinuation due to lack of tolerability was similar between the add-on and substitution groups. No difference between the add-on and substitution ASM introduction strategies was observed for the primary outcome of ≥50% seizure reduction at 12 months. SIGNIFICANCE Adding or substituting a new ASM in DRE has the same influence on seizure outcomes. The findings confirm that ASM alterations in DRE can be individualized according to concurrent ASM therapy and patient characteristics.
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Affiliation(s)
- Mubeen Janmohamed
- WA Adult Epilepsy Service, Perth, WA, Australia.,Central Clinical School, Monash University, Melbourne, Vic., Australia
| | | | - Katrina Spilsbury
- Institute for Health Research, The University of Notre Dame Australia, Fremantle, WA, Australia
| | | | - John Dunne
- WA Adult Epilepsy Service, Perth, WA, Australia.,School of Medicine, Royal Perth Hospital Unit, University of Western Australia, Perth, WA, Australia
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Lowerison MW, Josephson CB, Jetté N, Sajobi TT, Patten S, Williamson T, Deardon R, Barkema HW, Wiebe S. Association of Levels of Specialized Care With Risk of Premature Mortality in Patients With Epilepsy. JAMA Neurol 2020; 76:1352-1358. [PMID: 31380987 DOI: 10.1001/jamaneurol.2019.2268] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Patients with epilepsy are at an elevated risk of premature mortality. Interventions to reduce this risk are crucial. Objective To determine if the level of care (non-neurologist, neurologist, or comprehensive epilepsy program) is negatively associated with the risk of premature mortality. Design, Setting, and Participants In this retrospective open cohort study, all adult patients 18 years or older who met the administrative case definition for incident epilepsy in linked databases (Alberta Health Services administrative health data and the Comprehensive Calgary Epilepsy Programme Registry [CEP]) inclusive of the years 2002 to 2016 were followed up until death or loss to follow-up. The final analyses were performed on May 1, 2019. Exposures Evaluation by a non-neurologist, neurologist, or epileptologist. Main Outcomes and Measures The outcome was all-cause mortality. We used extended Cox models treating exposure to a neurologist or the CEP as time-varying covariates. Age, sex, socioeconomic deprivation, disease severity, and comorbid burden at index date were modeled as fixed-time coefficients. Results A total 23 653 incident cases were identified (annual incidence of 89 per 100 000); the mean age (SD) at index date was 50.8 (19.1) years and 12 158 (50.3%) were women. A total of 14 099 (60%) were not exposed to specialist neurological care, 9554 (40%) received care by a neurologist, and 2054 (9%) received care in the CEP. In total, 4098 deaths (71%) occurred in the nonspecialist setting, 1481 (26%) for those seen by a neurologist, and 176 (3%) for those receiving CEP care. The standardized mortality rate was 7.2% for the entire cohort, 9.4% for those receiving nonspecialist care, 5.6% for those seen by a neurologist, and 2.8% for those seen in the CEP. The hazard ratio (HR) of mortality was lower in those receiving neurologist (HR, 0.85; 95% CI, 0.77-0.93) and CEP (HR, 0.49; 95% CI, 0.38-0.62) care. In multivariable modeling, specialist care, the age at index, and disease severity were retained in the final model of the association between specialist care and mortality. Conclusions and Relevance Exposure to specialist care is associated with incremental reductions in the hazard of premature mortality. Those referred to a comprehensive epilepsy program received the greatest benefit.
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Affiliation(s)
- Mark W Lowerison
- O'Brien Institute for Public Health, Cumming School of Medicine, Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Colin B Josephson
- O'Brien Institute for Public Health, Cumming School of Medicine, Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nathalie Jetté
- O'Brien Institute for Public Health, Cumming School of Medicine, Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Department of Neurology, Icahn School of Medicine, New York, New York
| | - Tolulope T Sajobi
- O'Brien Institute for Public Health, Cumming School of Medicine, Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Scott Patten
- O'Brien Institute for Public Health, Cumming School of Medicine, Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tyler Williamson
- O'Brien Institute for Public Health, Cumming School of Medicine, Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Rob Deardon
- O'Brien Institute for Public Health, Cumming School of Medicine, Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Department of Production Animal Health, Faculty of Veterinary Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Mathematics and Statistics, Faculty of Science, University of Calgary, Calgary, Alberta, Canada
| | - Herman W Barkema
- O'Brien Institute for Public Health, Cumming School of Medicine, Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Department of Production Animal Health, Faculty of Veterinary Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Samuel Wiebe
- O'Brien Institute for Public Health, Cumming School of Medicine, Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Meador KJ, Pennell PB, May RC, Van Marter L, McElrath TF, Brown C, Gerard E, Kalayjian L, Gedzelman E, Penovich P, Cavitt J, French J, Hwang S, Pack AM, Sam M, Birnbaum AK, Finnell R. Fetal loss and malformations in the MONEAD study of pregnant women with epilepsy. Neurology 2020; 94:e1502-e1511. [PMID: 31806691 PMCID: PMC7251524 DOI: 10.1212/wnl.0000000000008687] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 10/11/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine occurrence of severe adverse fetal outcomes (SAO), including fetal loss and major congenital malformations (MCMs), in pregnant women with epilepsy (PWWE) vs healthy pregnant women (HPW). METHODS The Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study is an NIH-funded, prospective, observational, multicenter investigation of pregnancy outcomes for both mother and child, which enrolled women December 2012 through January 2016. RESULTS The 351 PWWE had 365 conceptions, and 105 HPW had 109 conceptions. SAOs occurred more often in PWWE (7.9%) vs HPW (1.9%) (p = 0.025) with odds ratio (OR) 4.45 (95% confidence intervals [CI] 1.04-19.01). There were no significant differences for fetal loss (2.8% vs 0%, p = 0.126) or MCMs (5.2% vs 1.9%, p = 0.185; OR 2.86, 95% CI 0.65-12.53) individually. No fetal losses in PWWE appeared to be related to acute seizures. Outcomes were not affected by periconceptional folate, unplanned/unwanted pregnancies, prior maternal pregnancy history, or antiepileptic drug (AED) blood levels, except for an AED level effect for fetal loss that appeared to be due to polytherapy. Combined maternal or paternal family history of MCM was marginally associated with increased SAOs (p = 0.046). CONCLUSIONS The findings provide additional information on risks of SAOs in PWWE, assessing effects of both AED levels and periconceptional folate. Group differences in average enrollment gestational age could have affected fetal loss results. Analyses are limited by small sample sizes as the MONEAD study was not powered for these secondary outcomes. The large majority of pregnancies in women with epilepsy do not have SOAs.
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Affiliation(s)
- Kimford J Meador
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX.
| | - Page B Pennell
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Ryan C May
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Linda Van Marter
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Thomas F McElrath
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Carrie Brown
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Elizabeth Gerard
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Laura Kalayjian
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Evan Gedzelman
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Patricia Penovich
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Jennifer Cavitt
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Jacqueline French
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Sean Hwang
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Alison M Pack
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Maria Sam
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Angela K Birnbaum
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Richard Finnell
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
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Quon RJ, Mazanec MT, Schmidt SS, Andrew AS, Roth RM, MacKenzie TA, Sajatovic M, Spruill T, Jobst BC. Antiepileptic drug effects on subjective and objective cognition. Epilepsy Behav 2020; 104:106906. [PMID: 32006792 PMCID: PMC7064420 DOI: 10.1016/j.yebeh.2020.106906] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 01/07/2020] [Accepted: 01/07/2020] [Indexed: 11/29/2022]
Abstract
RATIONALE Cognitive impairment is one of the most common complaints for persons with epilepsy (PWE). These impairments are not only associated with seizures, but are also regularly reported as adverse effects of antiepileptic drugs (AEDs). Previous studies have examined cognitive effects of both AED monotherapy and polytherapy, yet there is limited research on these differences with respect to both subjective and objective cognition. The current study uses data from previous research conducted by the Centers for Disease Control and Prevention (CDC)-sponsored Managing Epilepsy Well (MEW) Network collaborative. We used three distinct archival datasets from the following: (1) the HOBSCOTCH efficacy trial at Dartmouth-Hitchcock Medical Center (HOB-1), (2) the multisite replication trial (HOB-2), and (3) epilepsy self-management research conducted at the NYU School of Medicine. METHODS This retrospective analysis combined baseline data from three datasets to determine how the number of AEDs and the type of AEDs were associated with subjective (patient-reported) and objective (examiner-assessed) cognition. Subjective cognition was captured using the cognitive subscale of the Quality of Life in Epilepsy Inventory (QOLIE-31) in all three datasets (n = 224), while objective cognition was measured using the Repeated Battery for the Assessment of Neuropsychological Status (RBANS) in the HOB-1 dataset (n = 65) and the Brief Test of Adult Cognition by Telephone (BTACT) in the HOB-2 dataset (n = 91). Multivariable linear regression was utilized for our initial assessments, followed by propensity score matching to provide stronger control of covariates. Matching was based on significantly different covariates, such as education, depression, and history of prior epilepsy surgery. Nonparametric statistical tests were utilized to compare these matched subjects. RESULTS Subjective cognitive impairment was significantly worse among individuals on polytherapy (2 + AEDs) compared with those on monotherapy (1 AED) (adjusted p = 0.041). These findings were consistent with our propensity score matched comparison of monotherapy and polytherapy, which indicated that polytherapy was associated with worse overall subjective cognition (adjusted p = 0.01), in addition to impairments on the RBANS (Total score p = 0.05) and specific subdomains of the BTACT (Episodic Verbal Memory p < 0.01, Working Memory p < 0.01, Processing Speed p < 0.01). Interestingly, older generation AEDs were associated with better language performance than newer generation and combined generation AED therapy (RBANS Language p = 0.03). These language-specific findings remained significant after controlling for the effects of topiramate and zonisamide (p = 0.04). CONCLUSIONS A greater number of AEDs is significantly and negatively associated with subjective and objective cognition in PWE, and is in line with previous research. Antiepileptic drug type did not, in itself, appear to be associated with subjective cognition. Our findings suggest that ineffective AEDs should be replaced, rather than introducing additional AEDs to a treatment regimen. Further, while subjective and objective cognition assessments were both sensitive at detecting differences based on AED status, the neuropsychological objective subdomains offer additional and specific insights into how cognition is impaired with AEDs.
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Affiliation(s)
- Robert J Quon
- Department of Neurology, Geisel School of Medicine at Dartmouth, Hanover, NH, USA.
| | - Morgan T Mazanec
- Department of Neurology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Samantha S Schmidt
- Department of Neurology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Angeline S Andrew
- Department of Neurology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA; Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Robert M Roth
- Department of Psychiatry, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Todd A MacKenzie
- Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, NH, USA; The Dartmouth Institute, Dartmouth College, Hanover, NH, USA
| | - Martha Sajatovic
- Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Tanya Spruill
- Department of Population Health, New York University Langone, New York, NY, USA; Department of Medicine, New York University Langone, New York, NY, USA
| | - Barbara C Jobst
- Department of Neurology, Geisel School of Medicine at Dartmouth, Hanover, NH, USA; Department of Neurology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Weissinger F, Losch F, Winter Y, Brecht S, Lendemans D, Kockelmann E. Effectiveness of eslicarbazepine acetate in dependency of baseline anticonvulsant therapy: Results from a German prospective multicenter clinical practice study. Epilepsy Behav 2019; 101:106574. [PMID: 31678808 DOI: 10.1016/j.yebeh.2019.106574] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 08/23/2019] [Accepted: 09/14/2019] [Indexed: 11/25/2022]
Abstract
Eslicarbazepine acetate (ESL) is a third-generation antiepileptic drug (AED) approved as monotherapy for partial-onset seizures in adults and as adjunctive therapy in patients aged above 6 years in the European Union (EU). The prospective observational Zebinix Effects in DEpendency of BAseline Conditions (ZEDEBAC) study aimed at investigating the effectiveness of ESL in clinical practice, with ESL being administered as monotherapy (mono group), as only add-on to a current monotherapy (1+ group), or as add-on to ≥2 baseline AEDs (≥2+ group). In total, 237 patients were included, 35 in the mono group, 114 in the 1+, and 88 in the ≥2+ group. Six-month retention rates were 93.9%, 78.0%, and 75.3% in the mono, 1+, and ≥2+ group. There were 90.5%, 77.6%, and 48.3% of patients in the mono, 1+, and ≥2+ groups who were responders (patients with a ≥50% reduction in seizure frequency at follow-up vs. baseline). Seizure freedom rates were 81.5%, 47.9%, and 23.4%, respectively. Adverse drug reactions (ADRs) occurred in 11.4% of patients of the mono, 19.3% of the 1+, and 28.4% of patients of the ≥2+ group. Hyponatremia was reported as ADR in 3.4% of all patients. Although baseline variables differed considerably, with most elderly patients with tumor-related and vascular etiologies in the mono group and most patients with refractory epilepsies with pronounced use of concomitant sodium channel blockers (SCBs) in the ≥2+ group, retention as a measure of real-life effectiveness turned out not to be substantially different and favorable in all groups.
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Affiliation(s)
- Florian Weissinger
- Epilepsy Centre, Department of Neurology, Vivantes Humboldt Hospital, Am Nordgraben 2, 13509 Berlin, Germany; Department of Neurology, Charité University Hospital, Charitéplatz 1, 10117 Berlin, Germany
| | - Florian Losch
- Epilepsy Centre, Department of Neurology, Vivantes Humboldt Hospital, Am Nordgraben 2, 13509 Berlin, Germany
| | - Yaroslav Winter
- Mainz Comprehensive Epilepsy Center, Department of Neurology, Johannes Gutenberg-University, Langenbeckstr. 1, 55131 Mainz, Germany
| | - Silvia Brecht
- Eisai GmbH, Lyoner Str. 36, 60528 Frankfurt, Germany.
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Janmohamed M, Brodie MJ, Kwan P. Pharmacoresistance - Epidemiology, mechanisms, and impact on epilepsy treatment. Neuropharmacology 2019; 168:107790. [PMID: 31560910 DOI: 10.1016/j.neuropharm.2019.107790] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 09/01/2019] [Accepted: 09/21/2019] [Indexed: 12/25/2022]
Abstract
Understanding the natural history of and factors associated with pharmacoresistant epilepsy provides the foundation for formulating mechanistic hypotheses that can be evaluated to drive the development of novel treatments. This article reviews the modern definition of drug-resistant epilepsy, its prevalence and incidence, risk factors, hypothesized mechanisms, and the implication of recognizing pharmacoresistance in therapeutic strategies. This article is part of the special issue entitled 'New Epilepsy Therapies for the 21st Century - From Antiseizure Drugs to Prevention, Modification and Cure of Epilepsy'.
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Affiliation(s)
- Mubeen Janmohamed
- Department of Neuroscience, Alfred Hospital, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | | | - Patrick Kwan
- Department of Neuroscience, Alfred Hospital, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Departments of Medicine and Neurology, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.
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Lee BI, Park KM, Kim SE, Heo K. Clinical opinion: Earlier employment of polytherapy in sequential pharmacotherapy of epilepsy. Epilepsy Res 2019; 156:106165. [PMID: 31351239 DOI: 10.1016/j.eplepsyres.2019.106165] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 07/07/2019] [Indexed: 01/22/2023]
Abstract
Modern pharmacotherapy for epilepsy consists of orderly, sequential drug trials, in which antiepileptic drugs (AEDs) are chosen under the concept of individual patient-oriented (or - tailored) pharmacotherapy. Although monotherapy has been established as the preferred mode of AEDs therapy in both newly diagnosed and drug resistant epilepsies, there are still lack of evidence to favor either monotherapy or polytherapy in epilepsy, which has generated continuing controversies on the preferred mode of pharmacotherapy. However, each mode of pharmacotherapy may have both advantages and disadvantages, which are different and variable related to individual case scenario. We conducted a brief comparative overview between monotherapy and polytherapy to provide clues for earlier employment of polytherapy in each steps of sequential drug trials. Previous claims about the advantages of monotherapy over polytherapy are not supported but gradually losing its ground by the introduction of a large number of drugs carrying pharmacological advantages for combination therapy. Current evidence stresses the importance of combining drugs having synergistic interactions for better outcome of polytherapy, which has not been considered in previous clinical investigations comparing monotherapy and polytherapy. It is likely that a significant improvement in the outcome of current AEDs therapy is feasible by earlier employment of polytherapy as well as identification of combination drug regimens carrying synergistic interactions. At present, lamotrigine(LTG) and valproate(VPA) combination regimen is the only well documented synergistic regimen, but there are a long-list of candidate regimens requiring future trials in appropriate designs.
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Affiliation(s)
- Byung In Lee
- Department of Neurology and Epilepsy Center, Inje University Haeundae Paik Hospital, Busan, Republic of Korea.
| | - Kang Min Park
- Department of Neurology and Epilepsy Center, Inje University Haeundae Paik Hospital, Busan, Republic of Korea
| | - Sung Eun Kim
- Department of Neurology and Epilepsy Center, Inje University Haeundae Paik Hospital, Busan, Republic of Korea
| | - Kyoung Heo
- Department of Neurology, Yonsei University College of Medicine, Severance Hospital, Epilepsy Research Institute, Seoul, Republic of Korea
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Pimentel J, Lopes Lima JM. Rational polytherapy: Myth or reality? JOURNAL OF EPILEPTOLOGY 2019. [DOI: 10.21307/jepil-2019-003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Wang X, He R, Zeng Q, Wang Y, Zhu P, Bao Y, Du Y, Shen J, Zheng R, Xu H. Substitution has better efficacy than add-on therapy for patients with focal epilepsy after their first antiepileptic drug treatments fail. Seizure 2019; 64:23-28. [DOI: 10.1016/j.seizure.2018.11.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 11/27/2018] [Accepted: 11/29/2018] [Indexed: 10/27/2022] Open
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de Biase S, Gigli GL, Nilo A, Romano G, Valente M. Pharmacokinetic and pharmacodynamic considerations for the clinical efficacy of perampanel in focal onset seizures. Expert Opin Drug Metab Toxicol 2018; 15:93-102. [PMID: 30577702 DOI: 10.1080/17425255.2019.1560420] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Medical therapy is the mainstay of management of epilepsy. Despite the increasing number of available antiepileptic drugs (AEDs), approximately one-third of epileptic patients do not have adequate control of seizures. There is still a need for the development of new AEDs with enhanced effectiveness and tolerability. Areas covered: The present manuscript is based on an Internet and PubMed search (January 2005 to August 2018). It is focused on pharmacokinetic and clinical data of perampanel (PER) for the treatment of epilepsy. Expert opinion: PER has a novel mechanism of action, which opens up new options for a rational combination therapy. Phase III trials have demonstrated the efficacy and safety of PER as adjunctive therapy for the treatment of partial-onset seizures (POS) and primary generalized tonic-clonic seizures in patients aged ≥12 years. PER is also approved by FDA as monotherapy for the treatment of POS. A clinical trial is ongoing to verify the efficacy and safety of PER monotherapy in untreated patients with POS. In the future, head-to-head comparisons are needed to determine the exact position of PER relative to other AEDs. Moreover, further studies are needed to evaluate the efficacy and safety of PER in patients aged <12 years. ABBREVIATIONS 4βOHC: 4β-hydroxycholesterol; AUC: area under the curve; CBZ: Carbamazepine; CLCr: creatinine clearance; Cmax: maximum plasma concentration; CYP: cytochrome P; EIAED: enzyme-inducing antiepileptic drug; EMA: European Medicines Agency; FDA: Food and Drug Administration; GI: gastrointestinal; OXC: oxcarbazepine; PER: perampanel; PGTC: primary generalized tonic-clonic; PHT: phenytoin; POS: partial-onset seizures; QD: once-daily; TEAE: treatment-emergent adverse event; Tmax: median time to reach peak concentration; UGT: uridine diphosphoglucose-glucuronosyltransferase; VPA: valproic acid.
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Affiliation(s)
- Stefano de Biase
- a Neurology Unit, Department of Neurosciences , University Hospital of Udine , Udine , Italy
| | - Gian Luigi Gigli
- a Neurology Unit, Department of Neurosciences , University Hospital of Udine , Udine , Italy.,b DMIF , University of Udine , Udine , Italy
| | - Annacarmen Nilo
- a Neurology Unit, Department of Neurosciences , University Hospital of Udine , Udine , Italy
| | - Giorgia Romano
- c Pediatric Unit , University Hospital of Udine , Udine , Italy
| | - Mariarosaria Valente
- a Neurology Unit, Department of Neurosciences , University Hospital of Udine , Udine , Italy.,d Department of Medicine , University of Udine Medical School , Udine , Italy
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Vu LC, Piccenna L, Kwan P, O'Brien TJ. New-onset epilepsy in the elderly. Br J Clin Pharmacol 2018; 84:2208-2217. [PMID: 29856080 PMCID: PMC6138506 DOI: 10.1111/bcp.13653] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 05/02/2018] [Accepted: 05/02/2018] [Indexed: 12/30/2022] Open
Abstract
People who are 60 years old and older have the highest incidence of developing new-onset epilepsy. The increase of the ageing population has resulted in a greater number of patients with new-onset epilepsy or at risk of developing the condition. Previously published review articles regarding epilepsy in older patients have had a broad focus, including people who were diagnosed with epilepsy in their childhood or middle age. The present review focuses on the causes, treatment, prognosis and psychosocial impact of new-onset epilepsy in people aged ≥60 years. Following a search of the medical electronic databases and relevant references, we identified 22 studies overall that met the inclusion criteria. Only four randomized clinical trials (RCTs) were identified that compared different antiepileptic drug treatments in this population, demonstrating that newer-generation antiepileptic drugs (e.g. lamotrigine and levetiracetam) were generally better tolerated. One uncontrolled study provided promising evidence of good outcomes and safety for surgical resection as a treatment for people with uncontrolled seizures. Five studies reported that people ≥60 years with new-onset epilepsy have significant cognitive impairments (e.g. memory loss) and psychological issues including depression, anxiety and fatigue. We found that there is limited evidence to guide treatment in people with Alzheimer's disease and epilepsy. The specific features of new-onset epilepsy in this target population significantly influences the choice of treatment. Cognitive and psychiatric screening before treatment may be useful for management. Two studies with proposed guidelines were identified but no formal clinical practice guidelines exist for this special population to assist with appropriate management. There is a need for more RCTs that investigate effective treatments with limited side effects. More research studies on the psychosocial effects of new-onset epilepsy, and long-term outcomes, for people aged ≥60 years are also required.
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Affiliation(s)
- Lily Chi Vu
- Melbourne Brain Centre at the Royal Melbourne Hospital; Departments of Medicine and Neurology, Royal Melbourne HospitalUniversity of MelbourneMelbourneVictoria3050Australia
| | - Loretta Piccenna
- Departments of Neuroscience and Neurology, Central Clinical SchoolMonash University, The Alfred HospitalMelbourneVictoria3004Australia
| | - Patrick Kwan
- Melbourne Brain Centre at the Royal Melbourne Hospital; Departments of Medicine and Neurology, Royal Melbourne HospitalUniversity of MelbourneMelbourneVictoria3050Australia
- Departments of Neuroscience and Neurology, Central Clinical SchoolMonash University, The Alfred HospitalMelbourneVictoria3004Australia
| | - Terence J. O'Brien
- Melbourne Brain Centre at the Royal Melbourne Hospital; Departments of Medicine and Neurology, Royal Melbourne HospitalUniversity of MelbourneMelbourneVictoria3050Australia
- Departments of Neuroscience and Neurology, Central Clinical SchoolMonash University, The Alfred HospitalMelbourneVictoria3004Australia
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Błaszczyk B, Miziak B, Czuczwar P, Wierzchowska-Cioch E, Pluta R, Czuczwar SJ. A viewpoint on rational and irrational fixed-drug combinations. Expert Rev Clin Pharmacol 2018; 11:761-771. [PMID: 30024271 DOI: 10.1080/17512433.2018.1500895] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Considering that there are around 30% of patients with epilepsy resistant to monotherapy, the use of synergistic combinations of antiepileptic drugs is of particular importance. This review shows most beneficial as well as irrational combined treatments both from an experimental and clinical point of view. Areas covered: Preferably, experimental data derived from studies evaluating synergy, additivity, or antagonism by relevant methods, in terms of anticonvulsant or neurotoxic effects and pharmacokinetic data have been considered. Although there have been no randomized clinical trials on this issue, the clinical data have been analyzed from studies on considerable numbers of patients. Case-report studies have been not considered. Expert commentary: The experimental data provide a strong support that co-administration of lamotrigine with carbamazepine is negative, considering the anticonvulsant and neurotoxic effects. Clinical reports do not entirely support this conclusion. Other experimentally documented negative combinations comprise lamotrigine+ oxcarbazepine and oxcarbazepine+ phenytoin. From the experimental and clinical point of view, a combination of lamotrigine+ valproate may deserve recommendation. Other most positive experimental and clinical combinations include carbamazepine+valproate, phenytoin+phenobarbital, carbamazepine+gabapentin, carbamazepine+topiramate, levetiracetam+valproate, levetiracetam+carbamazepine. Certainly, experimental data have some limitations (non-epileptic animals, acute administration of antiepileptic drugs) so all experimental recommendations need a careful clinical evaluation.
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Affiliation(s)
- Barbara Błaszczyk
- a Faculty of Health Sciences , High School of Economics, Law and Medical Sciences , Kielce , Poland
| | - Barbara Miziak
- b Department of Pathophysiology , Medical University of Lublin , Lublin , Poland
| | - Piotr Czuczwar
- b Department of Pathophysiology , Medical University of Lublin , Lublin , Poland.,c 3rd Department of Gynecology , Medical University of Lublin , Lublin , Poland
| | - Ewa Wierzchowska-Cioch
- b Department of Pathophysiology , Medical University of Lublin , Lublin , Poland.,d Department of Neurology , Pope John Paul II Independent Public Provincial Hospital , Zamosc , Poland
| | - Ryszard Pluta
- e Laboratory of Ischemic and Neurodegenerative Brain Research , Mossakowski Medical Research Centre, Polish Academy of Sciences , Warszawa , Poland
| | - Stanisław J Czuczwar
- b Department of Pathophysiology , Medical University of Lublin , Lublin , Poland.,f Department of Physiopathology , Institute of Rural Health , Lublin , Poland
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Cognitive and fatigue side effects of anti-epileptic drugs: an analysis of phase III add-on trials. J Neurol 2018; 265:2137-2142. [PMID: 30003357 DOI: 10.1007/s00415-018-8971-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 07/05/2018] [Accepted: 07/06/2018] [Indexed: 10/28/2022]
Abstract
We aimed to investigate the terms used to refer to cognitive and fatigue related side effects and their prevalence in phase III add-on clinical trials of anti-epileptic drugs (AEDs). We extracted data from publicly available FDA documents as well as the published literature. Target drug doses were then calculated as drug loads and divided into three categories (low, average, high). The odds ratio of developing the side effects was calculated for each drug load, and the presence of a dose-response effect was also assessed. We found that the cognitive terms used across trials were very variable, and data on discontinuation rates were limited. Placebo rates for cognitive side effects ranged from 0 to 10.6% while those for fatigue ranged from 2.5 to 37.7%. Keeping in mind the variable placebo rates and terminology, the majority of AEDs exhibited a clear dose response effect and significant odds ratios at high doses except brivaracetam and zonisamide for the cognitive side effects and tiagabine, topiramate, and zonisamide for the fatigue side effects. Due to their clinical relevance and impact on quality of life, new trials should make data related to the prevalence and discontinuation rates of these side effects publicly available. Given the clear dose response effect, physicians should consider aiming for lower drug loads and adjusting doses to improve tolerability.
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Davis Jones G, Hitchcock A, Vajda F, Craig J, O'Brien TJ, Sen A. Development of EpiRisk: An online clinical tool for estimating the risk of major congenital malformations in pregnant women treated for epilepsy. Epilepsia Open 2018; 3:281-285. [PMID: 29881808 PMCID: PMC5983143 DOI: 10.1002/epi4.12109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2018] [Indexed: 11/10/2022] Open
Abstract
Antiepileptic drugs (AEDs) are known to associate with an increased risk of major congenital malformations (MCMs) in children born to women who become pregnant while taking them. As the indications for AEDs continue to diversify, novel AEDs emerge, and polytherapy becomes more prevalent, the volume and complexity of the information relating to teratogenic risk can become unmanageable for the clinician. This in turn makes accurate education of pregnant women treated with AEDs regarding the risk of MCMs challenging. To enable clinicians to provide better information regarding the potential teratogenic risk of AEDs, we outline here the method we have employed to underpin a new system of real-time risk analysis, "EpiRisk." When launched, EpiRisk will offer a user-friendly, online clinical tool, compatible with all modern Internet browsers, smart phones, and personal computers. Using the most current published data, as well as "real world" data from the UK and the Australian Pregnancy Registers, EpiRisk will enable clinicians to quickly and accurately assess the teratogenic risk of AEDs in mono- and polytherapy. EpiRisk may thus provide a future-proof central hub for empowering patients, clinicians, and registries by delivering evidence-based information on the teratogenic risk of the AEDs in pregnant women with epilepsy through an easily accessible platform.
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Affiliation(s)
- Gabriel Davis Jones
- Oxford Epilepsy Research Group NIHR Biomedical Research Centre Nuffield Department of Clinical Neurosciences John Radcliffe Hospital and The University of Oxford Oxford United Kingdom.,The Departments of Medicine and Neurology The Royal Melbourne Hospital The University of Melbourne Parkville Victoria Australia
| | - Alison Hitchcock
- The Departments of Medicine and Neurology The Royal Melbourne Hospital The University of Melbourne Parkville Victoria Australia.,Australian Pregnancy Register for Women on Antiepileptic Medication Melbourne Victoria Australia
| | - Frank Vajda
- The Departments of Medicine and Neurology The Royal Melbourne Hospital The University of Melbourne Parkville Victoria Australia.,Australian Pregnancy Register for Women on Antiepileptic Medication Melbourne Victoria Australia
| | - John Craig
- UK Epilepsy & Pregnancy Register Belfast United Kingdom
| | - Terence J O'Brien
- The Departments of Medicine and Neurology The Royal Melbourne Hospital The University of Melbourne Parkville Victoria Australia.,Australian Pregnancy Register for Women on Antiepileptic Medication Melbourne Victoria Australia.,The Department of Neurosciences and The Department of Neurology Central Clinical School The Alfred Hospital Monash University Melbourne Victoria Australia
| | - Arjune Sen
- Oxford Epilepsy Research Group NIHR Biomedical Research Centre Nuffield Department of Clinical Neurosciences John Radcliffe Hospital and The University of Oxford Oxford United Kingdom
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Legge AW, Detyniecki K, Javed A, Hirsch LJ, Kato K, Buchsbaum R, Chen B, Choi H. Comparative efficacy of unique antiepileptic drug regimens in focal epilepsy: An exploratory study. Epilepsy Res 2018; 142:73-80. [DOI: 10.1016/j.eplepsyres.2018.03.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 03/07/2018] [Accepted: 03/09/2018] [Indexed: 10/17/2022]
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Joshi R, Tripathi M, Gupta P, Gulati S, Gupta YK. Adverse effects & drug load of antiepileptic drugs in patients with epilepsy: Monotherapy versus polytherapy. Indian J Med Res 2018; 145:317-326. [PMID: 28749393 PMCID: PMC5555059 DOI: 10.4103/ijmr.ijmr_710_15] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background & objectives: Although the need for a combination of antiepileptic drugs (AEDs) in the treatment of epilepsy is well justified, but an associated increase in adverse effects (AEs) lends a restriction to polytherapy. The aim of this study was to evaluate AEs and drug load (prescribed daily dose/defined daily doses) of AEDs in patients with epilepsy (PWE). Methods: Consecutive PWEs attending Epilepsy clinic in a tertiary care hospital in New Delhi, India, were enrolled in the study. Demographic variables, such as age, gender, diagnosis, age at onset of seizures, frequency of seizures, use of all AEDs and adverse event profile (AEP) score were noted. Routine laboratory tests including lipid profile, fasting blood glucose, haematological parameters and liver and kidney function tests were done. Results: A total of 697 consecutive patients were included in this study. Of them, 64.4 per cent were male; mean age was 29.6 ± 10.6 yr. Generalized seizures and focal seizures were recorded in n=386 (55.4%) and n=311 (44.6%), respectively. Monotherapy and polytherapy with two and greater than or equal to three AEDs were prescribed in 264 (37.9%), 243 (34.9%) and 190 (27.2%) patients, respectively. The average AED load, duration of treatment as well as AEP score were found to be significantly higher in combination of greater than or equal to three AEDs as compared to both monotherapy and combination of two AEDs, whereas no significant difference was observed between monotherapy and combination of two AEDs. Patients on monotherapy were in good control of seizures as compared to polytherapy. There was no significant change in biochemical parameters between the groups. Interpretation & conclusions: Polytherapy with combination of greater than or equal to three AEDs was associated with higher AEs and lower seizure control as compared to both monotherapy and combination of two AEDs. AEs did not correlate with AED load, seizure type, gender and age of the patients but were associated with both numbers of AEDs as well as seizure frequency in PWE.
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Affiliation(s)
- Rupa Joshi
- Department of Pharmacology, Child Neurology Division, All India Institute of Medical Sciences, New Delhi, India
| | - Manjari Tripathi
- Department of Neurology, Child Neurology Division, All India Institute of Medical Sciences, New Delhi, India
| | - Pooja Gupta
- Department of Pharmacology, Child Neurology Division, All India Institute of Medical Sciences, New Delhi, India
| | - Sheffali Gulati
- Department of Paediatrics, Child Neurology Division, All India Institute of Medical Sciences, New Delhi, India
| | - Yogendra Kumar Gupta
- Department of Pharmacology, Child Neurology Division, All India Institute of Medical Sciences, New Delhi, India
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Wiśniowska B, Polak S. Drug-physiology interaction and its influence on the QT prolongation-mechanistic modeling study. J Pharmacokinet Pharmacodyn 2018; 45:483-490. [PMID: 29546612 DOI: 10.1007/s10928-018-9583-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 03/13/2018] [Indexed: 10/17/2022]
Abstract
The current study is an example of drug-disease interaction modeling where a drug induces a condition which can affect the pharmacodynamics of other concomitantly taken drugs. The electrophysiological effects of hypokaliemia and heart rate changes induced by the antiasthmatic drugs were simulated with the use of the cardiac safety simulator. Biophysically detailed model of the human cardiac physiology-ten Tusscher ventricular cardiomyocyte cell model-was employed to generate pseudo-ECG signals and QTc intervals for 44 patients from four clinical studies. Simulated and observed mean QTc values with standard deviation (SD) for each reported study point were compared and differences were analyzed with Student's t test (α = 0.05). The simulated results reflected the QTc interval changes measured in patients, as well as their clinically observed interindividual variability. The QTc interval changes were highly correlated with the change in plasma potassium both in clinical studies and in the simulations (Pearson's correlation coefficient > 0.55). The results suggest that the modeling and simulation approach could provide valuable quantitative insight into the cardiological effect of the potassium and heart rate changes caused by electrophysiologically inactive, non-cardiological drugs. This allows to simulate and predict the joint effect of several risk factors for QT prolongation, e.g., drug-dependent QT prolongation due to the ion channels inhibition and the current patient physiological conditions.
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Affiliation(s)
- Barbara Wiśniowska
- Pharmacoepidemiology and Pharmacoeconomics Unit, Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9, Str., 30-688, Krakow, Poland.
| | - Sebastian Polak
- Pharmacoepidemiology and Pharmacoeconomics Unit, Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9, Str., 30-688, Krakow, Poland.,Simcyp (Part of Certara), Sheffield, S2 4SU, UK
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Abstract
Monotherapy remains the standard initial therapy of epilepsy, but when the first antiepileptic drug (AED) fails, combination therapy may be considered. The choice of combination therapy should take into consideration pharmacokinetic interactions, as well as pharmacodynamic interactions related to mechanism of action. There is evidence that an AED combination with different mechanisms of action is more likely to be successful than a combination with the same mechanisms. The combination of lamotrigine and valproate has been demonstrated to be synergistic in its efficacy. However, there are limited data to support other synergistic AED combinations.
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Schoemaker R, Wade JR, D'Souza J, Stockis A. Evaluation of brivaracetam efficacy as monotherapy in adult patients with focal seizures. Epilepsy Res 2017; 137:95-100. [PMID: 28982069 DOI: 10.1016/j.eplepsyres.2017.09.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 08/25/2017] [Accepted: 09/16/2017] [Indexed: 11/16/2022]
Abstract
Brivaracetam is a selective, high-affinity ligand for synaptic vesicle protein 2A, recently approved as adjunctive therapy in the treatment of focal (partial-onset) seizures in patients 16 years of age and older with epilepsy. The goal of the present analysis was to determine if the dose-response of brivaracetam as monotherapy would fall within the range associated with brivaracetam efficacy as adjunctive therapy. An existing brivaracetam population pharmacokinetic model consisting of first-order absorption, single compartment distribution, and first-order elimination components was extended by estimating the clearance changes due to co-administration of 12 widely prescribed AEDs. Data for the population pharmacokinetic analysis originated from three Phase III add-on trials and two terminated Phase III monotherapy trials. An existing population model of daily seizure rate versus brivaracetam daily average concentration was applied to the data from the three add-on trials. Simulations allowed the assessment of the combined impact of covariate effects on both the pharmacokinetics and the pharmacodynamics of brivaracetam, and indicated that in the absence of other AEDs, only marginal changes in the overall dose-response relationship would be expected. This suggests that brivaracetam can be used as monotherapy without dose modifications.
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Brodie MJ. Pharmacological Treatment of Drug-Resistant Epilepsy in Adults: a Practical Guide. Curr Neurol Neurosci Rep 2017; 16:82. [PMID: 27443649 DOI: 10.1007/s11910-016-0678-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
More than 30 % of adults with epilepsy do not fully control on the currently available antiepileptic drugs (AEDs). For these and many other patients, combinations of agents, often possessing different mechanisms of actions, are employed with the aim of achieving seizure freedom or the best available prognosis in terms of reduced seizure numbers and severity. This review discusses my own approach to optimising outcomes in as many of these patients as possible by adjusting the drug burden using a combination of two, three or sometimes four or more AEDs. Modes of drug action are reviewed and practical strategies for treating different patients with drug-resistant epilepsy have been explored. Only for sodium valproate with lamotrigine is there good evidence of synergism. The final part of this practical paper consists of six individual illustrative cases with appropriate comments.
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Affiliation(s)
- Martin J Brodie
- Epilepsy Unit, West Glasgow ACH-Yorkhill, Dalnair Street, Glasgow, G3 8SJ, Scotland, UK.
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Baulac M, Byrnes W, Williams P, Borghs S, Webster E, De Backer M, Dedeken P. Lacosamide and sodium channel-blocking antiepileptic drug cross-titration against levetiracetam background therapy. Acta Neurol Scand 2017; 135:434-441. [PMID: 27714769 PMCID: PMC5347878 DOI: 10.1111/ane.12691] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2016] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To assess prospectively the effectiveness of lacosamide (LCM) added to levetiracetam (LEV) after down-titration of a concomitant sodium channel blocker (SCB) among patients with focal epilepsy not adequately controlled on LEV and SCB. METHODS In this open-label trial, LCM was initiated at 100 mg/day and up-titrated to 200-600 mg/day over 9 weeks; SCB down-titration started when LCM dose reached 200 mg/day. Patients remained on stable LCM/LEV doses for 12 weeks' maintenance (21-week treatment period). The primary outcome was retention rate on LCM. RESULTS Due to recruitment challenges, fewer than the planned 300 patients participated in the trial, resulting in the trial being underpowered. Overall, 120 patients (mean age 39.7 years) started and 93 completed the trial. The most frequently used SCBs were lamotrigine (39.2%), carbamazepine (30.8%) and oxcarbazepine (27.5%). Eighty-four patients adhered to protocol and discontinued their SCB after cross-titration, but there was insufficient evidence for 36 patients. Retention rate was 73.3% (88/120) for all patients and 83.3% (70/84) for those with evidence of SCB discontinuation. Seizure freedom for patients completing maintenance was 14.0% (13/93). Discontinuation due to adverse events (6.7%) and lack of efficacy (3.3%) occurred primarily during cross-titration. Most frequently reported adverse events during treatment were dizziness (23.3%), headache (15.0%) and fatigue (8.3%). CONCLUSIONS In patients with uncontrolled seizures on LEV/SCB, the LCM/LEV combination appeared to be effective and well tolerated. A cross-titration schedule-flexible LCM up-titration, concomitant SCB down-titration and stable background LEV-could present a feasible and practical approach to initiating LCM while minimizing pharmacodynamic interactions with a SCB.
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Affiliation(s)
- M. Baulac
- Pitié-Salpêtrière Hospital; IHU-ICM; Paris France
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Determining factors of electrocardiographic abnormalities in patients with epilepsy: A case-control study. Epilepsy Res 2016; 129:106-116. [PMID: 28043059 DOI: 10.1016/j.eplepsyres.2016.12.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 11/28/2016] [Accepted: 12/16/2016] [Indexed: 11/21/2022]
Abstract
Sudden unexpected death in epilepsy (SUDEP) is a major cause of mortality in young patients with epilepsy (PWE). Although its mechanisms are still poorly understood, they may include cardiorespiratory dysfunction. Standard 12-lead electrocardiograms (ECGs) were obtained from 62 consecutive patients (aged 18-66y) with a definite diagnosis of epilepsy, without seizures at the day of ECG, and 57 healthy controls matched for sex, age and body mass index (BMI). All ECGs were evaluated by a blinded board-certified cardiologist. Patients with symptomatic focal epilepsy represented 90.3% (N=56), of whom 56.4% (N=35) had temporal lobe epilepsy, with a mean duration of 22.02±14.96years of epilepsy. We observed more prolonged P-wave (p<0.0001) and PR interval (p=0.01) in patients than in controls. Additionally, longer QT intervals (p<0.01), pathologic QT dispersion (p<0.01) and left atrial overload (p<0.01) were more common in PWE. Multiple linear regression analysis evidenced age, gender and polytherapy as factors associated with altered ECG. Therefore, routine ECG should be requested in PWE, especially for males, increasing age and in polytherapy. Findings such as longer PR and QT interval, and pathologic QT dispersion, may reflect cardiac structural changes and/or autonomic nervous system dysfunction and indicate a risk for SUDEP.
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Villanueva V, Saiz-Diaz R, Toledo M, Piera A, Mauri JA, Rodriguez-Uranga JJ, López-González FJ, Gómez-Ibáñez A, Garcés M, González de la Aleja J, Rodríguez-Osorio X, Palao-Duarte S, Castillo A, Bonet M, Ruiz-Giménez J, Palau J, Arcediano A, Toledo M, Gago A. NEOPLASM study: Real-life use of lacosamide in patients with brain tumor-related epilepsy. Epilepsy Behav 2016; 65:25-32. [PMID: 27863278 DOI: 10.1016/j.yebeh.2016.09.033] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 09/02/2016] [Accepted: 09/19/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND The choice of antiepileptic drug (AED) therapy in patients with brain tumor-related epilepsy (BTRE) is complicated, and there are a lack of robust clinical trial data to date. METHODS The NEOPLASM (Neuroncologic Patients treated with LAcoSaMide) study was a 6-month, multicenter, retrospective, observational study in patients with BTRE treated with lacosamide. Patients were started on lacosamide because of a lack of efficacy or adverse events (AEs) with prior AEDs or suitability versus other AEDs, according to clinical practice. The primary efficacy variable was the seizure-free rate at 6months. Safety variables included the proportion of patients with an AE and the proportion with an AE that led to discontinuation. RESULTS Overall, 105 patients from 14 hospital centers were included in the analysis. Treatment with lacosamide for 6months resulted in a 30.8% seizure-free rate, and 66.3% of patients had a ≥50% seizure reduction (responders). In the subset of patients included because of a lack of efficacy with prior AEDs, seizure-free rates were 28.0%, and 66.7% of patients were responders. No statistically significant differences in efficacy were observed according to the mechanism of action or enzyme-inducing properties of concomitant AEDs. Adverse events were reported by 41.9% of patients at 6months, and 4.7% of them led to discontinuation. The most common AEs were somnolence/fatigue and dizziness. Notably, 57.1% of the patients who were switched to lacosamide because of AEs with their previous therapy did not report any AE at 6-month follow-up. CONCLUSIONS In this open-label, observational study, lacosamide appeared to be effective and well tolerated in a large population of patients with BTRE. Lacosamide may therefore be a promising option for the treatment of patients with BTRE.
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Affiliation(s)
- Vicente Villanueva
- Hospital Universitario y Politécnico La Fe, Bulevard Sur, s/n, Carretera de Malilla, 46026 Valencia, Spain.
| | - Rosana Saiz-Diaz
- Hospital Universitario 12 de Octubre, Avda de Córdoba, s/n, 28041 Madrid, Spain
| | - Manuel Toledo
- Hospital Universitario Vall d'Hebron, Passeig de la Vall d'Hebron, 119-129, 08035 Barcelona, Spain
| | - Ana Piera
- Hospital Clínico Universitario Valencia, Spain
| | - Jose Angel Mauri
- Hospital Clínico Universitario Lozano Blesa, Calle de San Juan Bosco, 15, 50009 Zaragoza, Spain
| | | | | | - Asier Gómez-Ibáñez
- Hospital Universitario y Politécnico La Fe, Bulevard Sur, s/n, Carretera de Malilla, 46026 Valencia, Spain
| | - Mercedes Garcés
- Hospital Universitario y Politécnico La Fe, Bulevard Sur, s/n, Carretera de Malilla, 46026 Valencia, Spain
| | | | | | | | - Ascensión Castillo
- Consorcio Hospital General Universitario de Valencia, Av Tres Cruces, 2, 46014, Valencia, Spain
| | - Macarena Bonet
- Hospital Arnau de Vilanova, Calle San Clemente, 12, 46015, Valencia, Spain
| | - Jesús Ruiz-Giménez
- Hospital Universitario Virgen de las Nieves, Avenida de las Fuerzas Armadas, 2, 18014 Granada, Spain
| | - Juan Palau
- Hospital Manises Avenidad Generalitat Valenciana, 46940 Manises, Spain
| | | | - Maria Toledo
- Hospital Universitario La Princesa Madrid, Calle Diego de León, Madrid, Spain
| | - Ana Gago
- Hospital Universitario La Princesa Madrid, Calle Diego de León, Madrid, Spain
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49
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Tan SM, Wan YM. Pramipexole in the treatment of REM sleep behaviour disorder: A critical review. Psychiatry Res 2016; 243:365-72. [PMID: 27449005 DOI: 10.1016/j.psychres.2016.06.055] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 06/27/2016] [Accepted: 06/29/2016] [Indexed: 11/15/2022]
Abstract
While widely accepted as a first-line treatment for rapid eye movement sleep (REM) behaviour disorder, clonazepam (CNZP) has side effects that limit its applicability. Pramipexole is a possible alternative, but limited literature on its effectiveness exists. This review aims to summarize the available data on the use of pramipexole in REM sleep behaviour disorder. A systematic search of major databases was conducted to look for published and on-going trials. This search yielded a total of five articles, all of which are observational in nature. Factors associated with effectiveness include low doses (less than 1.5mg/day) and idiopathic rapid eye movement sleep behaviour disorder/absence of neurodegenerative disease. Overall, the evidence is inconclusive. This is due to the lack of randomised controlled trials and the challenges in interpreting polysomgraphy findings in rapid eye movement sleep behaviour disorder. Suggestions are given on how future trials evaluating pramipexole treatment in rapid eye movement sleep behaviour disorder could overcome current methodological issues in extant literature.
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Affiliation(s)
| | - Yi Min Wan
- Ng Teng Fong General Hospital, Singapore.
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50
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Scarlatelli-Lima AV, Sukys-Claudino L, Watanabe N, Guarnieri R, Walz R, Lin K. How do people with drug-resistant mesial temporal lobe epilepsy sleep? A clinical and video-EEG with EOG and submental EMG for sleep staging study. eNeurologicalSci 2016; 4:34-41. [PMID: 29430547 PMCID: PMC5803108 DOI: 10.1016/j.ensci.2016.06.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 05/23/2016] [Accepted: 06/08/2016] [Indexed: 11/29/2022] Open
Abstract
This study aimed to assess subjective and objective sleep parameters in a homogeneous group of drug-resistant mesial temporal lobe epilepsy (MTLE) patients through internationally validated clinical questionnaires, video-electroencephalographic (VEEG) and polysomnographic (PSG) studies. Fifty-six patients with definite diagnosis of MTLE who were candidates for epilepsy surgery underwent a detailed clinical history, the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), Stanford Sleepiness Scale (SSS), neurological examination, 1.5 T brain magnetic resonance imaging, VEEG and PSG. Sixteen percent of patients reported significant daytime sleepiness as measured by ESS and 27% reported low levels of sleep quality as measured by PSQI. Patients with medically resistant epilepsy by MTLE showed increased wakefulness after sleep onset (WASO) with mean ± standard deviation of 17.4 ± 15.6, longer non-rapid eye movement (NREM) 1 (7.5 ± 4.6%) and NREM3 sleep (26.6 ± 11.8%), abnormal rapid eye movement (REM) latency in 30/56 patients, shorter REM sleep (16.7 ± 6.6%), and abnormal alpha delta patterns were observed in 41/56 patients. The analysis of interictal epileptic discharges (IEDs) evidenced highest spiking rate during NREM3 sleep and higher concordance with imaging data when IEDs were recorded in sleep, mainly during REM sleep. We concluded that patients with MTLE showed disrupted sleep architecture that may result in daytime dysfunction and sleep complaints. Furthermore, NREM sleep activated focal IEDs and them - when recorded during sleep - had higher localizing value.
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Affiliation(s)
| | - Lucia Sukys-Claudino
- Centro de Epilepsia de Santa Catarina (CEPESC), Hospital Governador Celso Ramos (HGCR), Florianópolis, SC, Brazil
- Serviço de Neurologia, Departamento de Clínica Médica, Hospital Universitário, Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil
- Centro de Neurociências Aplicadas (CeNAp), Hospital Universitário, Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil
| | - Nancy Watanabe
- Centro de Neurociências Aplicadas (CeNAp), Hospital Universitário, Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil
| | - Ricardo Guarnieri
- Centro de Epilepsia de Santa Catarina (CEPESC), Hospital Governador Celso Ramos (HGCR), Florianópolis, SC, Brazil
- Centro de Neurociências Aplicadas (CeNAp), Hospital Universitário, Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil
| | - Roger Walz
- Centro de Epilepsia de Santa Catarina (CEPESC), Hospital Governador Celso Ramos (HGCR), Florianópolis, SC, Brazil
- Serviço de Neurologia, Departamento de Clínica Médica, Hospital Universitário, Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil
- Centro de Neurociências Aplicadas (CeNAp), Hospital Universitário, Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil
| | - Katia Lin
- Centro de Epilepsia de Santa Catarina (CEPESC), Hospital Governador Celso Ramos (HGCR), Florianópolis, SC, Brazil
- Serviço de Neurologia, Departamento de Clínica Médica, Hospital Universitário, Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil
- Centro de Neurociências Aplicadas (CeNAp), Hospital Universitário, Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil
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