The unmet need for rapid epileptic seizure termination (REST)

Treatment administration during a seizure in home-settings: Time to treat (TT)

BACKGROUND AND OBJECTIVE

Early intervention on prolonged and cluster seizures can avoid serious consequences such as irreversible neuronal damage, late onset epileptogenesis, sudden unexpected death, and premature death, among others. In addition, it can prevent progression to status epilepticus, which has a mortality rate of 20%. However, prehospital diagnosis and treatment of seizures is often delayed, as patients receive treatment 30minutes past seizure onset even though most seizures last less than 2minutes. The aim of this consensus was to determine the time at which rapid and early seizure termination (REST) drugs should be administered in home-settings.

MATERIALS AND METHODS

Eleven epileptologists reviewed and discussed the scientific literature in face-to-face work meetings, followed by individual work. Recommendations for the management of prolonged and cluster seizures in the home-setting were established.

RESULTS

Patients with epilepsy should be considered candidates to receive REST treatment in home-seeting if they are at risk of prolonged seizures or clusters, as well as if they experience prodromal symptoms, auras, or epileptic seizures that alert of a more severe seizure that lead to impaired consciousness or generalize tonic-clonic. Additionally, this treatment should be considered for individuals who, despite not having epilepsy, are at risk of experiencing a seizure, such as those with a history of febrile seizures, acute brain injuries with seizures, or patients undergoing withdrawal from anti-seizure treatment. The general recommendation is to administer REST treatment two minutes after the onset of a seizure or when clustered seizures occur at twice the usual frequency within an eight-hour period. In cases of generalized tonic-clonic seizures, intervention should be even more prompt. Treatment timing should always be individualized for each patient, considering the characteristics of their usual seizures. The neurologist must prescribe the medication with instructions for it to be administered in the patient's home setting.

CONCLUSIONS

In general, the administration of REST medications by non-healthcare personnel should follow these recommendations: medication should be given for epileptic seizures lasting 2minutes or in cases where the frequency of seizures doubles compared to usual. This is crucial in most cases, while always considering the recommendations of the physician.

Medications used for seizure-emergency management in the UK community: A clinical practice research datalink retrospective database study

OBJECTIVE

Assess the prevalence, characteristics, and healthcare resource utilization (HCRU) of patients prescribed certain benzodiazepines for seizure-emergency management in the United Kingdom.

METHODS

Retrospective cohort study using Clinical Practice Research Datalink (CPRD-Aurum) and Hospital Episode Statistics (HES) data that included patients with ≥1 recorded seizure-emergency medication prescription between 2016 and 2020. Patient characteristics were described for the whole sample. Inpatient, outpatient, and Accident and Emergency (A&E) encounters during 2019 were described. The 2019 prevalence of seizure-emergency medication prescription among patients with epilepsy was calculated.

RESULTS

In 2019, 6.7% (9336/139667) of CPRD-Aurum patients with epilepsy were prescribed seizure-emergency medication. Between 2016 and 2020, 26 534 patients with seizure-emergency medication were identified (mean/median age: 41.5/41.0 years [71.8% were adults]; 50.3% male). In this sample, the most prescribed seizure-emergency medication was buccal midazolam (60.6% of patients). Rectal diazepam was prescribed for 19.0%; oral benzodiazepines for 20.3%. Of the oral benzodiazepines prescribed for seizure-emergency management, oral diazepam was most common (97.5%). Buccal midazolam was prescribed both to children and adults (44.2%/55.8%); rectal diazepam and oral benzodiazepines mainly to adults (93.3%/99.5%). Among 11 594 patients with HES linkage in 2019, 25.1% experienced ≥1 epilepsy-specific inpatient hospitalization (median hospitalization days in patients with ≥1 hospitalization = 2.9 [IQR 12.0]); 35.7% had ≥1 neurology-specific outpatient visit (median visits in patients with ≥1 visit = 2.6 [3.4]); 8.7% had ≥1 epilepsy-related emergency attendance (median attendances in patients with ≥1 attendance = 3.0 [4.0]); 7.8% arrived in A&E by ambulance due to epilepsy (median arrivals in patients with ≥1 arrival = 2.2 [3.4]).

SIGNIFICANCE

In 2019, 6.7% of patients with epilepsy were prescribed seizure-emergency medication. Nevertheless, patients continue to encounter challenges to manage seizure-related emergencies, as shown by high HCRU, suggesting that it may be time for a new treatment paradigm. The recently proposed concept of Rapid and Early Seizure Termination (REST) warrants further investigation.

PLAIN LANGUAGE SUMMARY

In people with epilepsy, some seizures last too long and will not stop on their own, or may happen one after another, becoming emergencies that need medical attention; seizure-emergency medications are given to stop the seizure and prevent other medical problems. We looked at the share of people with epilepsy who had a seizure-emergency medication prescription in a UK database, and this group's use of health services. In 2019, 7% of people with epilepsy were prescribed a seizure-emergency medication. Use of health services was high in this group, highlighting the need for better treatment options.

Immediate Treatment of Seizure Clusters: A Conceptual Roadmap to Expedited Seizure Management

Some patients with epilepsy continue to have seizures despite daily treatment with antiseizure medications. This includes seizure clusters (also known as acute repetitive seizures), which are an increase in seizure frequency that is different from the usual seizure pattern for that patient. In the literature, the term "rescue" is used for pharmacologic treatment for seizure clusters, but clarity regarding timing or whether a caregiver or patient should wait until a moment of life-threatening urgency before administering the medication is lacking. Additionally, the concept of waiting 5 minutes to identify and initiate treatment of status epilepticus has been carried over to the treatment of seizure clusters, as well as the idea of waiting owing to safety concerns, without reevaluation in the context of the reported safety profiles for currently available as-needed therapies when administered as prescribed. Delaying treatment of seizure clusters may have negative outcomes, including injury, emergency room use, hospitalization, and progression to status epilepticus. Additionally, increased time for administration of benzodiazepines, the cornerstone therapies for seizure clusters, may lower the potency and effectiveness once administration takes place, because of physiologic changes. Thus, clarifying the importance of timing in the treatment terminology may be of benefit in the acute context. The term "immediate-use seizure medication" (ISM), meaning treatment that is administered as quickly as possible once a seizure cluster is recognized, may help to clarify the timing of as-needed treatment. This review examines the recognition and definitions of seizure clusters, the physiologic rationale for ISM for seizure clusters, and the effectiveness and safety of early treatment. Remaining knowledge gaps are also discussed. The findings of this review suggest that it may be time to revisit the terminology of "rescue", which implies waiting to administer treatment for seizure clusters, as doing so is not supported by pathophysiologic, effectiveness, or safety data.

Outpatient management of prolonged seizures and seizure clusters to prevent progression to a higher-level emergency: Consensus recommendations of an expert working group

OBJECTIVE

The management of prolonged seizures (PS) and seizure clusters (SC) is impeded by the lack of international, evidence-based guidance. We aimed to develop expert recommendations regarding consensus definitions of PS, SC, and treatment goals to prevent progression to higher-level emergencies such as status epilepticus (SE).

METHODS

An expert working group, comprising 12 epileptologists, neurologists, and pharmacologists from Europe and North America, used a modified Delphi consensus methodology to develop and anonymously vote on statements. Consensus was defined as ≥75% voting "Agree"/"Strongly agree."

RESULTS

All group members strongly agreed that termination of an ongoing seizure in as short a time as possible is the primary goal of rapid and early seizure termination (REST) and that an ideal medication for REST would start to act within 2 min of administration to terminate ongoing seizure activity. Consensus was reached on the terminology defining PS (with proposed thresholds of 5 min for prolonged focal seizures and 2 min for prolonged absence seizures and the convulsive phase of bilateral tonic-clonic seizures) and SC (an abnormal increase in seizure frequency compared with the individual patient's usual seizure pattern). All group members strongly agreed or agreed that patients who have experienced a PS should be offered a REST medication, and all patients who have experienced a SC should be offered an acute cluster treatment (ACT). Further, when prescribing a REST medication or ACT, a seizure action plan should be agreed upon in consultation with the patient and caregiver.

SIGNIFICANCE

The expert working group had a high level of agreement on the recommendations for defining and managing PS and SC. These recommendations will complement the existing guidance for the management of acute seizures, with the possibility of treating them earlier to potentially avoid progression to more severe seizures, including SE.

Short-Term Impact of Seizures and Mitigation Opportunities

PURPOSE OF REVIEW

The burden of epilepsy is complex and consists of elements directly related to acute seizures as well as those associated with living with a chronic neurologic disorder. The purpose of this systematic review was to characterize short-term burdens of seizures and to explore the potential value of acute treatments to mitigate these burdens apart from reducing the risk of status epilepticus.

RECENT FINDINGS

A systematic literature search was conducted using PubMed to identify articles published from January 1, 2017, to June 22, 2023, that described short-term burdens and acute treatments of seizures. Primary outcomes included those related to short-term burdens of seizures and the benefits of acute treatments to reduce short-term burdens. Of the 1332 articles identified through PubMed and 17 through other sources, 27 had relevant outcomes and were included in the qualitative synthesis. Seizure emergencies negatively affected short-term quality of life and the ability to conduct normal daily living activities and were associated with physical (injury) and financial (emergency transport, hospitalization) burdens. The use of acute treatment was associated with a rapid return (≤ 1 h) to normal function/self for both patients and caregivers and potentially lower healthcare utilization and costs. Seizure action plans may improve knowledge and comfort with seizure care, empowering patients and caregivers. The short-term burden of seizures can create a substantial negative impact on patients and caregivers. Acute treatments may reduce the short-term burdens of seizures in addition to their well-described role to reduce seizure activity and the risk for status epilepticus.

Narrative Review of Brivaracetam: Preclinical Profile and Clinical Benefits in the Treatment of Patients with Epilepsy

One third of patients with epilepsy will continue to have uncontrolled seizures despite treatment with antiseizure medications (ASMs). There is therefore a need to develop novel ASMs. Brivaracetam (BRV) is an ASM that was developed in a major drug discovery program aimed at identifying selective, high-affinity synaptic vesicle protein 2A (SV2A) ligands, the target molecule of levetiracetam. BRV binds to SV2A with 15- to 30-fold higher affinity and greater selectivity than levetiracetam. BRV has broad-spectrum antiseizure activity in animal models of epilepsy, a favorable pharmacokinetic profile, few clinically relevant drug-drug interactions, and rapid brain penetration. BRV is available in oral and intravenous formulations and can be initiated at target dose without titration. Efficacy and safety of adjunctive BRV (50-200 mg/day) treatment of focal-onset seizures was demonstrated in three pivotal phase III trials (NCT00490035/NCT00464269/NCT01261325), including in patients who had previously failed levetiracetam. Efficacy and safety of adjunctive BRV were also demonstrated in adult Asian patients with focal-onset seizures (NCT03083665). In several open-label trials (NCT00150800/NCT00175916/NCT01339559), long-term safety and tolerability of adjunctive BRV was established, with efficacy maintained for up to 14 years, with high retention rates. Evidence from daily clinical practice highlights BRV effectiveness and tolerability in specific epilepsy patient populations with high unmet needs: the elderly (≥ 65 years of age), children (< 16 years of age), patients with cognitive impairment, patients with psychiatric comorbid conditions, and patients with acquired epilepsy of specific etiologies (post-stroke epilepsy/brain tumor related epilepsy/traumatic brain injury-related epilepsy). Here, we review the preclinical profile and clinical benefits of BRV from pivotal trials and recently published evidence from daily clinical practice.

Pharmacokinetics of Staccato® alprazolam in healthy adult participants in two phase 1 studies: An open-label smoker study and a randomized, placebo-controlled ethnobridging study

OBJECTIVE

Staccato® alprazolam is a single-use, drug-device combination delivering alprazolam to the deep lung that is being evaluated as treatment for rapid and early seizure termination. This article reports pharmacokinetic (PK) data from two phase 1 studies of Staccato alprazolam in healthy adult participants.

METHODS

The smoker study (EPK-002/NCT03516305) was an open-label, nonrandomized, single-dose, PK study in smokers and nonsmokers aged 21-50 years, administered a single inhaled dose of 1 mg Staccato alprazolam. The ethnobridging study (UP0101/NCT04782388) was a double-blind, placebo-controlled study in Japanese, Chinese, and Caucasian participants aged 18-55 years randomized 4:1 to a single inhaled dose of Staccato alprazolam 2 mg or Staccato placebo.

RESULTS

In the smoker study, 36 participants (18 smokers, 18 nonsmokers) were enrolled and received Staccato alprazolam. Following Staccato administration, alprazolam was rapidly absorbed, with a median time to peak drug plasma concentration (Tmax) of 2 min in both smokers (range = 2-30 min) and nonsmokers (range = 2-60 min). Staccato alprazolam was rapidly absorbed to a similar extent in both smokers and nonsmokers. The most commonly reported treatment-emergent adverse events (TEAEs) were somnolence and dizziness. In the ethnobridging study, 10 participants each of Japanese, Chinese, and Caucasian ethnicities were randomized 4:1 to Staccato alprazolam or Staccato placebo. Following Staccato administration, alprazolam was rapidly absorbed and distributed, with a median Tmax of 1.5-2 min in Japanese (range = 1-2 min), Chinese (range = 1-34 min), and Caucasian (range = 1-120 min) participants. Somnolence and sedation were the most commonly reported TEAEs. In both studies, there were no deaths, and no participants reported serious or severe TEAEs, or discontinued due to TEAEs.

SIGNIFICANCE

Alprazolam was rapidly absorbed, and therapeutic drug levels were achieved within 2 min postdose when administered to the lung with the Staccato device. Staccato alprazolam was generally well tolerated and displayed a safety profile consistent with that known from other alprazolam applications. No new safety signals were identified.

Acute Abortive Therapies for Seizure Clusters in Long-Term Care

OBJECTIVES

To describe acute seizure treatment for the long-term care setting, emphasizing rescue (acute abortive) medications for on-site management of acute unexpected seizures and seizure clusters.

DESIGN

Narrative review.

SETTING AND PARTICIPANTS

People with seizures in long-term care, including group residences.

METHODS

PubMed was searched using keywords that pertained to rescue medications, seizure emergencies/epilepsy, seizure action plans, and long-term care.

RESULTS

Seizure disorder, including epilepsy, is prevalent in long-term care residences, and rescue medications can be used for on-site treatment. Diazepam rectal gel, intranasal midazolam, and diazepam nasal spray are US Food and Drug Administration (FDA)-approved seizure-cluster rescue medications, and intravenous diazepam and lorazepam are approved for status epilepticus. Benzodiazepines differ by formulation, route of administration, absorption, and metabolism. Intranasal formulations are easy and ideal for public use and when rectal treatment is challenging (eg, wheelchair). Intranasal, intrabuccal, and rectal formulations do not require specialized training to administer and are easier for staff at all levels of training compared with intravenous treatment. Off-label rescue medications may have anecdotal support; however, potential disadvantages include variable absorption and onset of action as well as potential risks to patients and caregivers/care partners. Delivery of intravenous-administered rescue medications is delayed by the time needed to set up and deliver the medication and is subject to dosing errors. Seizure action plans that include management of acute seizures can optimize the quality and timing of treatment, which may reduce emergency service needs and prevent progression to status epilepticus.

CONCLUSIONS AND IMPLICATIONS

Seizure disorder is prevalent across all ages but is increased in older adults and in those with intellectual and developmental disabilities. Prompt intervention may reduce negative outcomes associated with acute unexpected seizures and seizure clusters. Seizure action plans that include acute seizures can improve the treatment response by detailing the necessary information for staff to provide immediate treatment.

A randomized phase 2b efficacy study in patients with seizure episodes with a predictable pattern using Staccato® alprazolam for rapid seizure termination

OBJECTIVE

Alprazolam administered via the Staccato® breath-actuated device is delivered into the deep lung for rapid systemic exposure and is a potential therapy for rapid epileptic seizure termination (REST). We conducted an inpatient study (ENGAGE-E-001 [NCT03478982]) in patients with stereotypic seizure episodes with prolonged or repetitive seizures to determine whether Staccato alprazolam rapidly terminates seizures in a small observed population after administration under direct supervision.

METHODS

Adult patients with established diagnosis of focal and/or generalized epilepsy with a documented history of seizure episodes with a predictable pattern were enrolled. They were randomized 1:1:1 to double-blind treatment of a single seizure event with one dose of Staccato alprazolam 1.0 mg or 2.0 mg, or Staccato placebo in an inpatient unit. The primary end point of the study was the proportion of responders in each treatment group achieving seizure activity cessation within 2 min after administration of study drug and no recurrence of seizure activity within 2 h.

RESULTS

A total of 273 patients were screened, and 116 randomized patients received treatment with the study drug in the double-blind part. The proportion of treated patients who were responders was 65.8% for each of Staccato alprazolam 1.0 mg (n = 38; p = .0392) and 2.0 mg (n = 38; p = .0392), compared with 42.5% for Staccato placebo (n = 40). Staccato alprazolam was well tolerated when administered as a single dose of 1.0 or 2.0 mg: cough and somnolence were the most common adverse events (AEs) (both 14.5%), followed by dysgeusia (13.2%). AEs were mostly mild or moderate in intensity; there were no treatment-related serious AEs.

SIGNIFICANCE

Both 1.0 mg and 2.0 mg doses of Staccato alprazolam demonstrated efficacy in rapidly terminating seizures in an inpatient setting and were well tolerated. The next step is a Phase 3 confirmatory study to demonstrate efficacy and safety of Staccato alprazolam for rapid cessation of seizures in an outpatient setting.

Recent advances in drug delivery to the central nervous system by inhalation

INTRODUCTION

Drugs need to enter the systemic circulation efficiently before they can cross the blood-brain barrier and reach the central nervous system. Although the respiratory tract is not a common route of administration for delivering drugs to the central nervous system, it has attracted increasing interest in recent years for this purpose.

AREAS COVERED

In this article, we compare pulmonary delivery to three other common routes (parenteral, oral, and intranasal) for delivering drugs to the central nervous system, followed by summarising the devices used to aerosolise neurological drugs. Recent studies delivering drugs for different neurological disorders via inhalation are then discussed to illustrate the strengths of pulmonary delivery.

EXPERT OPINION

Recent studies provide strong evidence and rationale to support inhaling neurological drugs. Since inhalation can achieve improved pharmacokinetics and rapid onset of action for multiple drugs, it is a non-invasive and efficient method to deliver drugs to the central nervous system. Future research should focus on delivering other small and macro-molecules via the lungs for different neurological conditions.

Rescue therapies in epilepsy

PURPOSE OF REVIEW

The purpose of this review is to provide a succinct evaluation of the current rescue medications and action plans available to our patients with seizure clusters in the outpatient setting.

RECENT FINDINGS

The main themes of the recent findings are that rescue medications and seizure action plans (SAPs) are underutilized, particularly in the adult population. The safety and efficacy of intranasal midazolam and intranasal diazepam is comparable with rectal diazepam for the treatment of seizure clusters. Additionally, this intranasal formulation has the benefit of a more socially acceptable route of administration and ease of use.

SUMMARY

The implication of these findings is a greater variety and awareness in the rescue medications available to our patients suffering from seizure clusters.

Permanent loss of independence in adult febrile-infection-related epilepsy syndrome survivors: an underestimated and unsolved challenge

BACKGROUND AND PURPOSE

Febrile-infection-related epilepsy syndrome (FIRES) is an exceedingly rare and devastating subtype of new-onset refractory status epilepticus, which causes refractory epilepsy and permanent neurocognitive impairment.

METHODS

This was a long-term follow-up of adult FIRES survivors treated between 2005 and 2018 as part of the EpiCARE initiative, a European Reference Network for rare and complex epilepsies. Clinical, electroencephalography, imaging and functional outcome measures are described using the Scores of Independence for Neurologic and Geriatric Rehabilitation, the modified Rankin Scale and the Global Assessment of Severity of Epilepsy Scale.

RESULTS

Six patients with refractory epilepsy following FIRES were evaluated. Despite general improvement after intensive care unit discharge, disease severity was still high at follow-up in all patients. The functional outcome, as assessed by the modified Rankin Scale, was moderately impaired in 2/6 patients. In contrast, the Scores of Independence for Neurologic and Geriatric Rehabilitation indicated a loss of independence in 5/6, serious problems in memory and planning/problem-solving in 4/6 and serious attentional problems in 3/6 patients.

CONCLUSIONS

Febrile-infection-related epilepsy syndrome survivors may regain vital functions and mobility but experience a significant loss of independence and participation due to recurring seizures, structural brain damage and neurocognitive decline. Minimization of disastrous outcomes through the systematic evaluation of rescue therapies within a network of specialized centres is crucial.

Vagus Nerve Electroneurogram-Based Detection of Acute Pentylenetetrazol Induced Seizures in Rats

On-demand stimulation improves the efficacy of vagus nerve stimulation (VNS) in refractory epilepsy. The vagus nerve is the main peripheral parasympathetic connection and seizures are known to exhibit autonomic symptoms. Therefore, we hypothesized that seizure detection is possible through vagus nerve electroneurogram (VENG) recording. We developed a metric able to measure abrupt changes in amplitude and frequency of spontaneous vagus nerve action potentials. A classifier was trained using a "leave-one-out" method on a set of 6 seizures and 3 control recordings to utilize the VENG spike feature-based metric for seizure detection. We were able to detect pentylenetetrazol (PTZ) induced acute seizures in 6/6 animals during different stages of the seizure with no false detection. The classifier detected the seizure during an early stage in 3/6 animals and at the onset of tonic clonic stage of the seizure in 3/6 animals. EMG and motion artefacts often accompany epileptic activity. We showed the "epileptic" neural signal to be independent from EMG and motion artefacts. We confirmed the existence of seizure related signals in the VENG recording and proved their applicability for seizure detection. This detection might be a promising tool to improve efficacy of VNS treatment by developing new responsive stimulation systems.