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Le Roux M, Benallegue N, Gueden S, Rupin-Mas M, Van Bogaert P. Care of pharmaco-resistant absence seizures in childhood. Rev Neurol (Paris) 2024; 180:251-255. [PMID: 38388226 DOI: 10.1016/j.neurol.2024.01.002] [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: 11/16/2023] [Revised: 01/03/2024] [Accepted: 01/08/2024] [Indexed: 02/24/2024]
Abstract
In childhood absence epilepsy, pharmaco-resistance occurs in 20-30% of patients. In that situation, glucose transporter type 1 deficiency has to be ruled out, especially if absences started before the age of four years and if neurological signs are present. If ethosuximide, valproate and lamotrigine have failed in monotherapy or in association, there are currently no valuable therapeutic options. The same rules apply for epilepsy with myoclonic absences. Importantly, arguments supporting that making the patient seizure-free will improve eventual associated cognitive deficits such as attention deficit are very weak. Therefore, limiting the cognitive side effects of the anti-epileptic drugs has always to be a priority when faced with typical refractory absences in childhood. In epilepsy with eyelid myoclonia, the majority of patients are pharmaco-resistant. However, absence seizures, if present, tend to be very brief, and seizures are limited in many patients to eyelid myoclonia that eventually do not affect their quality of life and are well attenuated by wearing blue lenses. Atypical absences occurring in the course a developmental and/or epileptic encephalopathy are often pharmaco-resistant. In that situation, characterizing the type of epilepsy syndrome and searching for a specific genetic or structural etiology are needed to offer the best therapeutic options to the patient.
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Affiliation(s)
- M Le Roux
- Department of Pediatric Neurology, CHU d'Angers, Angers, France
| | - N Benallegue
- Department of Pediatric Neurology, CHU d'Angers, Angers, France
| | - S Gueden
- Department of Pediatric Neurology, CHU d'Angers, Angers, France
| | - M Rupin-Mas
- Department of Pediatric Neurology, CHU d'Angers, Angers, France
| | - P Van Bogaert
- Department of Pediatric Neurology, CHU d'Angers, Angers, France; Laboratoire Angevin de Recherche en Ingénierie des Systèmes (LARIS), Université d'Angers, Angers, France.
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Gidal BE, Resnick T, Smith MC, Wheless JW. Zonisamide: A Comprehensive, Updated Review for the Clinician. Neurol Clin Pract 2024; 14:e200210. [PMID: 38170117 PMCID: PMC10759004 DOI: 10.1212/cpj.0000000000200210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/15/2023] [Indexed: 01/05/2024]
Abstract
Purpose of Review Zonisamide (ZNS) was first approved in the United States in 2000 for the adjunctive treatment of patients aged 16 years or older with partial (focal) seizures. Although ZNS has been proven to treat multiple seizure types, it has been largely underutilized in US clinical practice. Recent Findings Published literature demonstrated that antiseizure medications (ASMs) acting on Na+ and Ca2+ channels may add beneficial effects in many seizure types by reducing seizure frequency and leading to overall improvements. In addition, effects of ZNS may lead to clinical improvements in Parkinson disease, alcohol and sleep disorders, pain, and migraine. ZNS is available in multiple formulations and is a safe and effective, broad spectrum ASM. Summary The purpose of this review was to provide an update to what is known about the efficacy of ZNS and where it shows benefits in the treatment of patients with epilepsy and other CNS disorders through its many unique mechanisms of action.
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Affiliation(s)
- Barry E Gidal
- Pharmacy Practice & Translational Research (BEG), University of Wisconsin-Madison; Department of Neurology (TR), Nicklaus Children Hospital; Department of Neurology, Florida International University, Miami, FL; Department of Neurological Sciences (MCS), Rush Medical College; Rush University Medical Center, Chicago, IL; and Pediatric Neurology (JWW), University of Tennessee Health Science Center; Neuroscience Institute & Le Bonheur Comprehensive Epilepsy Program, Le Bonheur Children's Hospital, Memphis, TN
| | - Trevor Resnick
- Pharmacy Practice & Translational Research (BEG), University of Wisconsin-Madison; Department of Neurology (TR), Nicklaus Children Hospital; Department of Neurology, Florida International University, Miami, FL; Department of Neurological Sciences (MCS), Rush Medical College; Rush University Medical Center, Chicago, IL; and Pediatric Neurology (JWW), University of Tennessee Health Science Center; Neuroscience Institute & Le Bonheur Comprehensive Epilepsy Program, Le Bonheur Children's Hospital, Memphis, TN
| | - Michael C Smith
- Pharmacy Practice & Translational Research (BEG), University of Wisconsin-Madison; Department of Neurology (TR), Nicklaus Children Hospital; Department of Neurology, Florida International University, Miami, FL; Department of Neurological Sciences (MCS), Rush Medical College; Rush University Medical Center, Chicago, IL; and Pediatric Neurology (JWW), University of Tennessee Health Science Center; Neuroscience Institute & Le Bonheur Comprehensive Epilepsy Program, Le Bonheur Children's Hospital, Memphis, TN
| | - James W Wheless
- Pharmacy Practice & Translational Research (BEG), University of Wisconsin-Madison; Department of Neurology (TR), Nicklaus Children Hospital; Department of Neurology, Florida International University, Miami, FL; Department of Neurological Sciences (MCS), Rush Medical College; Rush University Medical Center, Chicago, IL; and Pediatric Neurology (JWW), University of Tennessee Health Science Center; Neuroscience Institute & Le Bonheur Comprehensive Epilepsy Program, Le Bonheur Children's Hospital, Memphis, TN
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Rinaldi VE, Di Cara G, Mencaroni E, Verrotti A. Therapeutic Options for Childhood Absence Epilepsy. Pediatr Rep 2021; 13:658-667. [PMID: 34941639 PMCID: PMC8705546 DOI: 10.3390/pediatric13040078] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 12/02/2021] [Accepted: 12/09/2021] [Indexed: 11/30/2022] Open
Abstract
Childhood absence epilepsy (CAE) is a common pediatric generalized epileptic syndrome. Although it is traditionally considered as a benign self-limited condition, the apparent benign nature of this syndrome has been revaluated in recent years. This is mainly due to the increasing evidence that children with CAE can present invalidating neuropsychological comorbidities that will affect them up to adulthood. Moreover, a percentage of affected children can develop drug-resistant forms of CAE. The purpose of this review is to summarize the most recent studies and new concepts concerning CAE treatment, in particular concerning drug-resistant forms of CAE. A Pubmed search was undertaken to identify all articles concerning management and treatment of CAE, including articles written between 1979 and 2021. Traditional anticonvulsant therapy of CAE that is still in use is based on three antiepileptic drugs: ethosuximide which is the drug of choice, followed by valproic acid and lamotrigine. In the case of first line treatment failure, after two monotherapies it is usual to start a bi-therapy. In the case of absence seizures that are refractory to traditional treatment, other antiepileptic drugs may be introduced such as levetiracetam, topiramate and zonisamide.
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Affiliation(s)
| | - Giuseppe Di Cara
- Pediatric Unit, Department of Medicine and Surgery, University of Perugia, 06156 Perugia, Italy; (G.D.C.); (E.M.); (A.V.)
| | - Elisabetta Mencaroni
- Pediatric Unit, Department of Medicine and Surgery, University of Perugia, 06156 Perugia, Italy; (G.D.C.); (E.M.); (A.V.)
| | - Alberto Verrotti
- Pediatric Unit, Department of Medicine and Surgery, University of Perugia, 06156 Perugia, Italy; (G.D.C.); (E.M.); (A.V.)
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Mastroianni G, Ascoli M, Gasparini S, Brigo F, Cianci V, Neri S, Russo E, Aguglia U, Ferlazzo E. Therapeutic approach to difficult-to-treat typical absences and related epilepsy syndromes. Expert Rev Clin Pharmacol 2021; 14:1427-1433. [PMID: 34289757 DOI: 10.1080/17512433.2021.1959317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction: typical absences (TAs), are brief, generalized epileptic seizures of abrupt onset and termination clinically manifesting with impairment of awareness and associated with 3 Hz spike-wave discharges on EEG. TAs may occur in different idiopathic generalized epilepsies (IGE). Despite treatment with adequate anti-seizure medications (ASMs), TAs may persist in ~25% of subjects. This narrative review focuses on the therapeutic approach to difficult-to-treat TAs occurring in the setting of IGE.Areas covered: a literature search was conducted on the topic of treatment of TAs.Expert opinion: ethosuximide (ESX), valproic acid (VPA) and lamotrigine (LTG), alone or in combination, are considered the first-choice drugs. In women of childbearing potential, VPA should be avoided. Alternative therapies (benzodiazepines, levetiracetam, topiramate, or zonisamide) should be considered in subjects unresponsive to monotherapy after the exclusion of pseudo-drug resistance. Newer ASMs such as brivaracetam and perampanel seem to be promising options. Well-conducted clinical trials aimed to evaluate the efficacy of alternative monotherapy (beyond ESX, VPA or LTG) or combination of ASMs on difficult-to-treat TAs, are warranted.
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Affiliation(s)
- Giovanni Mastroianni
- Regional Epilepsy Centre, Great Metropolitan "BMM" Hospital, Reggio, Calabria, Italy
| | - Michele Ascoli
- Regional Epilepsy Centre, Great Metropolitan "BMM" Hospital, Reggio, Calabria, Italy.,Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Sara Gasparini
- Regional Epilepsy Centre, Great Metropolitan "BMM" Hospital, Reggio, Calabria, Italy.,Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano, Italy
| | - Vittoria Cianci
- Regional Epilepsy Centre, Great Metropolitan "BMM" Hospital, Reggio, Calabria, Italy
| | - Sabrina Neri
- Regional Epilepsy Centre, Great Metropolitan "BMM" Hospital, Reggio, Calabria, Italy.,Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Emilio Russo
- Science of Health Department, Magna Graecia University, Catanzaro, Italy
| | - Umberto Aguglia
- Regional Epilepsy Centre, Great Metropolitan "BMM" Hospital, Reggio, Calabria, Italy.,Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy.,Institute of Molecular Bioimaging and Physiology, National Research Council, Catanzaro, Italy
| | - Edoardo Ferlazzo
- Regional Epilepsy Centre, Great Metropolitan "BMM" Hospital, Reggio, Calabria, Italy.,Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy.,Institute of Molecular Bioimaging and Physiology, National Research Council, Catanzaro, Italy
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Abstract
Childhood absence epilepsy (CAE) is a common pediatric epilepsy syndrome with distinct seizure semiology, electroencephalography (EEG) features, and treatment. A diagnosis of CAE can be obtained during an office visit with a careful history, physical exam including prolonged hyperventilation, and a routine EEG. The treatment of choice for CAE with absence seizures only is ethosuximide. Valproic acid and lamotrigine are also effective treatments for many patients, but when compared to ethosuximide, valproic acid has more adverse effects and lamotrigine is less effective. Attention to predictors of response to treatment, including clinical, electrographic, and genetic factors, is increasing. Refractory CAE occurs in fewer than half of patients, and treatment strategies are available, though efficacy data are lacking. Careful assessment and treatment of psychosocial comorbidities is essential in caring for patients with CAE.
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Affiliation(s)
- Sudha Kilaru Kessler
- Perelman School of Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.
| | - Emily McGinnis
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA USA
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Garzon P, Lemelle L, Auvin S. Épilepsie absence de l’enfant : actualités diagnostiques et thérapeutiques. Arch Pediatr 2016; 23:1176-1183. [DOI: 10.1016/j.arcped.2016.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 06/19/2016] [Accepted: 08/22/2016] [Indexed: 10/21/2022]
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Camacho Velásquez JL, Rivero Sanz E, Sanabria Sanchinel AA, Santos Lasaosa S, Mauri Llerda JA. Difficulties in diagnosing absence seizures in adults. Neurologia 2016; 33:S0213-4853(16)30047-0. [PMID: 27289346 DOI: 10.1016/j.nrl.2016.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 03/12/2016] [Accepted: 04/04/2016] [Indexed: 12/01/2022] Open
Affiliation(s)
- J L Camacho Velásquez
- Servicio de Neurología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España.
| | - E Rivero Sanz
- Servicio de Neurología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | | | - S Santos Lasaosa
- Servicio de Neurología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - J A Mauri Llerda
- Servicio de Neurología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
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Cognitive Profile of Zonisamide and Valproic Acid in the Treatment of Idiopathic Generalized Epilepsy: A Comparative Observational Study. Neurol Ther 2016; 5:59-68. [PMID: 27086007 PMCID: PMC4919133 DOI: 10.1007/s40120-016-0043-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Calls for an alternative to valproic acid (VPA) as drug of choice for idiopathic generalized epilepsies (IGEs) have intensified since the recent International League Against Epilepsy recommendation that the drug should not be administered to women of childbearing age. Zonisamide (ZNS), a third-generation antiepileptic drug, has proven effective in generalized seizures and could be considered an alternative to VPA in this population. OBJECTIVES The present study was designed to examine possible differences in cognitive profile between ZNS and VPA as monotherapy in patients with IGE in real-life settings. METHODS We conducted a comparative, descriptive, observational, retrospective cohort study in two groups of patients diagnosed with IGE treated with ZNS ≥200 mg/day or VPA ≥1000 mg/day as stable monotherapy for at least the previous 6 months. We used specific neuropsychological tests for short- and long-term mnemonic functions, working memory, visuospatial speed, attention and processing speed, verbal fluency, executive functions, visual perception, abstraction, anxiety, depression, and apathy. RESULTS We included 16 patients in the study: eight in the VPA and eight in the ZNS group. Significantly superior mean scores were obtained by the VPA group in working memory (Forward Digits test) and by the ZNS group in execution time for the Rey-Osterrieth complex figure test. No statistically significant differences were found between the groups in the remaining tests. CONCLUSION Zonisamide as monotherapy has a similar cognitive profile to that of VPA in patients with IGE. The final treatment selection setting should be individualized. ZNS may be a reasonable alternative to VPA in some cases in this population.
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Velizarova R, Crespel A, Genton P, Serafini A, Gelisse P. Zonisamide for refractory juvenile absence epilepsy. Epilepsy Res 2014; 108:1263-6. [DOI: 10.1016/j.eplepsyres.2014.04.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Revised: 03/31/2014] [Accepted: 04/27/2014] [Indexed: 10/25/2022]
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Matricardi S, Verrotti A, Chiarelli F, Cerminara C, Curatolo P. Current advances in childhood absence epilepsy. Pediatr Neurol 2014; 50:205-12. [PMID: 24530152 DOI: 10.1016/j.pediatrneurol.2013.10.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2013] [Revised: 10/06/2013] [Accepted: 10/12/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Childhood absence epilepsy is an age-dependent, idiopathic, generalized epilepsy with a characteristic seizure appearance. The disorder is likely to be multifactorial, resulting from interactions between genetic and acquired factors, but the debate is still open. We review recent studies on different aspects of childhood absence epilepsy and also to describe new concepts. METHODS Data for this review were identified using Medline and PubMed survey to locate studies dealing with childhood absence epilepsy. Searches included articles published between 1924 and 2013. RESULTS The diagnosis comprises predominant and associated seizure types associated with other clinical and electroencephalographic characteristics. Many studies have challenged the prevailing concepts, particularly with respect to the pathophysiological mechanisms underlying the electroencephalographic seizure discharges. Childhood absence epilepsy fits the definition of system epilepsy as a condition resulting from the persisting susceptibility of the thalamocortical system as a whole to generate seizures. This syndrome, if properly defined using strict diagnostic criteria, has a good prognosis. In some cases, it may affect multiple cognitive functions determining risk for academic and functional difficulties; the detection of children at risk allows tailored interventions. Childhood absence epilepsy is usually treated with ethosuximide, valproate, lamotrigine, or levetiracetam, but the most efficacious and tolerable initial empirical treatment has not been well defined. CONCLUSIONS We review recent studies and new concepts on the electroclinical features and pathophysiological findings of childhood absence epilepsy in order to highlight areas of consensus as well as areas of uncertainty that indicate directions for future research.
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Affiliation(s)
- Sara Matricardi
- Department of Pediatrics, University "G. D'Annunzio" of Chieti, Chieti, Italy.
| | | | - Francesco Chiarelli
- Department of Pediatrics, University "G. D'Annunzio" of Chieti, Chieti, Italy
| | - Caterina Cerminara
- Department of Neurosciences, Pediatric Neurology Unit Tor Vergata University, Rome, Italy
| | - Paolo Curatolo
- Department of Neurosciences, Pediatric Neurology Unit Tor Vergata University, Rome, Italy
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Abstract
The availability of new antiepileptic drugs with different mechanisms of action has widened our therapeutic choice, allowing better tailoring of treatment regimens to address specific needs. Zonisamide is the latest addition to the pharmacological management of epilepsy in Europe, following extensive clinical experience in Japan and the USA. This article reviews the structure, mechanism of action, pharmacokinetics and drug interactions of zonisamide. The four double-blind, placebo-controlled trials in patients with drug-resistant focal seizures are also presented. They complement pre- and postmarketing studies conducted in Japan and provide clear-cut evidence that the drug has efficacy as an add-on treatment in this indication. Reports on zonisamide monotherapy and on the use of the drug for the control of several types of seizures (typical and atypical absences, tonic and myoclonic) and syndromes in children and adults are also commented on. These were all open-label studies, as is often the case with other antiepileptic drugs, dealing with treatment of epilepsy in children. The Japanese, US and European data provide a large database of safety information suggesting that the drug is well tolerated with mild-to-moderate adverse events (e.g., somnolence and dizziness). Nephrolithiasis appears to have a very low incidence and cutaneous reactions are rare. The available data provide an excellent foundation on which clinicians can build their knowledge on this drug, although the broad-spectrum efficacy of zonisamide needs to be confirmed through randomized trials.
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Affiliation(s)
- Alexis Arzimanoglou
- Epilepsy Program, University Hospital Robert Debré, Child Neurology Metabolic Diseases Department, 48 Boulevard Sérurier, 75019 Paris, France.
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Burakgazi E, Dalkilic A, Moghal U, Shah U, Carran M. A case of atypical absence seizures after electroconvulsive treatment in a patient with treatment-resistant depression. Clin EEG Neurosci 2013; 44:62-9. [PMID: 23248334 DOI: 10.1177/1550059412452674] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Electroconvulsive therapy (ECT) has been used to treat severe treatment-resistant major depressive disorder. Multiple psychotropic medications are usually prescribed in high doses prior to or concomitantly with ECT. Little is known about the interaction of ECT with psychotropic medications. ECT is known to induce seizures, but its tendency to induce absence seizures is not. We present a case of a 44-year-old female, on multiple psychotropic medications, who had frequent atypical absence seizures for many days after ECT. Electroencephalography (EEG) confirmed atypical absence seizures by the presence of typical 2.5 to 3 Hz generalized sharp and slow waves with disorganized background activity.
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Beydoun A, D'Souza J. Treatment of idiopathic generalized epilepsy – a review of the evidence. Expert Opin Pharmacother 2012; 13:1283-98. [DOI: 10.1517/14656566.2012.685162] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Gursahani R, Gupta N. The adolescent or adult with generalized tonic-clonic seizures. Ann Indian Acad Neurol 2012; 15:81-8. [PMID: 22566718 PMCID: PMC3345605 DOI: 10.4103/0972-2327.94988] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Revised: 01/03/2012] [Accepted: 02/25/2012] [Indexed: 01/26/2023] Open
Abstract
Primary and secondary generalized tonic-clonic seizures (GTCs) together constitute up to 50% of adolescent and adult patients with epilepsy as diagnosed by history and EEG. Syncope and psychogenic nonepileptic seizures are major differential diagnoses and must be carefully excluded in therapy-resistant cases. Individual episodes can have up to seven phases in secondarily generalized GTCs. The distinction between primary and secondary GTCs depends mainly on history and EEG, and yield can be improved with sleep deprivation or overnight recording. Epilepsies with primary or unclassified GTCs can respond to any one of the five broad-spectrum antiepileptic drugs (AEDs): valproate, lamotrigine, levetiracetam, topiramate and zonisamide. Unless a focal onset is clearly confirmed, a sodium-channel blocking AED should not be used in the initial treatment of these conditions.
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Affiliation(s)
- Roop Gursahani
- Department of Neurology, P.D. Hinduja National Hospital, Mumbai, India
| | - Namit Gupta
- Department of Neurology, Sir J.J. Hospital, Mumbai, India
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Abstract
OPINION STATEMENT Antiepileptic drugs (AEDs) are the mainstay of treatment for recurrent seizures. Uncontrolled seizures may cause medical, developmental, and psychological disturbances. The medical practitioner should thus strive to eliminate or minimize seizures. Treatment advances in epilepsy include 1) identification of the basic mechanisms of epilepsy and action of AEDs, 2) the introduction of new AEDs, and 3) the use of neurostimulation, including vagus nerve stimulation. Treatment with AEDs involves balancing each AED's efficacy against its side effects. In some patients, effective AEDs must be discontinued because of intolerable side effects. Although all AEDs have a proven efficacy, the choice of AEDs should be based on better efficacy for individual seizure types or epilepsy syndromes. Side effects also differ from drug to drug and must be taken into account. This article focuses on studies and expert opinion consensus to guide the choice of AEDs.
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Eun SH, Kim HD, Eun BL, Lee IK, Chung HJ, Kim JS, Kang HC, Lee YM, Suh ES, Kim DW, Eom S, Lee JS, Moon HK. Comparative trial of low- and high-dose zonisamide as monotherapy for childhood epilepsy. Seizure 2011; 20:558-63. [DOI: 10.1016/j.seizure.2011.04.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Revised: 03/29/2011] [Accepted: 04/01/2011] [Indexed: 10/18/2022] Open
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Verrotti A, Loiacono G, Coppola G, Spalice A, Mohn A, Chiarelli F. Pharmacotherapy for children and adolescents with epilepsy. Expert Opin Pharmacother 2011; 12:175-94. [PMID: 21208135 DOI: 10.1517/14656566.2010.517194] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Childhood epilepsies are the most frequent neurological problems that occur in children. Despite the introduction of new antiepileptic drugs (AEDs) 25-30% of children with epilepsy remain refractory to medical therapy. AREAS COVERED This review aims to highlight the main published data on the treatment of childhood epilepsy. The electronic database, PubMed, and abstract proceedings were used to identify studies. The aim of antiepileptic therapy should be to provide complete seizure control, if possible without the burden of any side effect. Since 1993, new agents have been approved for use as an antiepileptic. Although there are few published data (especially in pediatric populations) to establish that the second-generation AEDs are more efficacious than the older AEDs, they appear to have better tolerability. EXPERT OPINION Old AEDs are efficacious agents that continue to play a major role in the current treatment of epilepsy. These agents actually remain the first-line treatment for many specific seizure types or epileptic syndromes. The new AEDs were initially approved as adjunct agents and--subsequently--as monotherapy for various seizure types in the adult and children. Despite these improvements, few AEDs are now considered to be a first-choice for the treatment of epilepsy in children.
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Affiliation(s)
- Alberto Verrotti
- University of Chieti, Department of Pediatrics, Ospedale Policlinico, Via dei Vestini 5, Chieti, Italy.
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Abou-Khalil BW. Levetiracetam efficacy in idiopathic generalized epilepsy: long suspected and now confirmed in randomized clinical trials. Epilepsy Curr 2010; 8:16-8. [PMID: 18265883 DOI: 10.1111/j.1535-7511.2007.00221.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Placebo-Controlled Study of Levetiracetam in Idiopathic Generalized Epilepsy. Berkovic SF, Knowlton RC, Leroy RF, Schiemann J, Falter U; On behalf of the Levetiracetam N01057 Study Group. Neurology. 2007;68 [Epub ahead of print]. Objective To assess the efficacy and tolerability of adjunctive levetiracetam in patients with uncontrolled generalized tonicclonic (GTC) seizures associated with idiopathic generalized epilepsies (IGE). Methods This multicenter, randomized, double-blind, placebo-controlled, parallel-group study enrolled adults and children (4 to 65 years) with IGE experiencing 3 GTC seizures during the 8-week baseline period (4-week retrospective and 4-week prospective), despite receiving stable doses of one or two antiepileptic drugs (AEDs). Patients were randomized to levetiracetam (target dose 3,000 mg/day for adults; 60 mg/kg/day for children) or placebo and a 4-week titration period was followed by a 20-week evaluation period. Results Of 229 patients screened, 164 were randomized (levetiracetam, n = 80; placebo, n = 84). Levetiracetam produced a greater mean reduction in GTC seizure frequency per week over the treatment period (56.5%) than placebo (28.2%; p = 0.004). The percentage of patients who had 50% reduction of GTC seizure frequency per week (responders) during the treatment period was 72.2% for levetiracetam and 45.2% for placebo ( p < 0.001; OR 3.28; 95% CI 1.68 to 6.38). During the first 2-week treatment 64.6% of patients on levetiracetam and 45.2% on placebo ( p = 0.018) were classified as responders. During the evaluation period the percent of patients free of GTC seizures (34.2% vs 10.7%; p < 0.001) and all seizure types (24.1% vs 8.3%; p = 0.009) was greater for levetiracetam than placebo. Levetiracetam was well tolerated with 1.3% of patients discontinuing therapy due to adverse events vs 4.8% on placebo. Conclusion Adjunctive levetiracetam is an effective and well-tolerated antiepileptic drug for treating generalized tonic-clonic seizures in patients with idiopathic generalized epilepsies.
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Handforth A, Homanics GE, Covey DF, Krishnan K, Lee JY, Sakimura K, Martin FC, Quesada A. T-type calcium channel antagonists suppress tremor in two mouse models of essential tremor. Neuropharmacology 2010; 59:380-7. [PMID: 20547167 DOI: 10.1016/j.neuropharm.2010.05.012] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2009] [Revised: 05/14/2010] [Accepted: 05/24/2010] [Indexed: 11/17/2022]
Abstract
Essential tremor is a common disorder that lacks molecular targets for therapeutic development. T-type calcium channel activation has been postulated to underlie rhythmicity in the olivo-cerebellar system that is implicated in essential tremor. We therefore tested whether compounds that antagonize T-type calcium channel currents suppress tremor in two mouse models that possess an essential tremor-like pharmacological response profile. Tremor was measured using digitized spectral motion power analysis with harmaline-induced tremor and in the GABA(A) receptor α1 subunit-null model. Mice were given ethosuximide, zonisamide, the neuroactive steroid (3β,5α,17β)-17-hydroxyestrane-3-carbonitrile (ECN), the 3,4-dihydroquinazoline derivative KYS05064, the mibefradil derivative NNC 55-0396, or vehicle. In non-sedating doses, each compound reduced harmaline-induced tremor by at least 50% (range of maximal suppression: 53-81%), and in the GABA(A) α1-null model by at least 70% (range 70-93%). Because the T-type calcium channel Cav3.1 is the dominant subtype expressed in the inferior olive, we assessed the tremor response of Cav3.1-deficient mice to harmaline, and found that null and heterozygote mice exhibit as much tremor as wild-type mice. In addition, ECN and NNC 55-0396 suppressed harmaline tremor as well in Cav3.1-null mice as in wild-type mice. The finding that five T-type calcium antagonists suppress tremor in two animal tremor models suggests that T-type calcium channels may be an appropriate target for essential tremor therapy development. It is uncertain whether medications developed to block only the Cav3.1 subtype would exhibit efficacy.
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Affiliation(s)
- Adrian Handforth
- Neurology Service (W127), Veterans Affairs Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA 90073, USA.
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Abstract
The newer antiepileptic drugs (AEDs) provide more therapeutic options and overall improved safety and tolerability for patients. To provide the best care, physicians must be familiar with the latest tolerability and safety data. This is particularly true in children, given there are relatively fewer studies examining the effects of AEDs in children compared with adults. Since we now have significant paediatric literature on each of these agents, we provide a comprehensive and current literature review of the newer AEDs, focusing on safety and tolerability data in children and adolescents. Because the safety profiles in children differ from those in adults, familiarity with this literature is important for child neurologists and other paediatric caregivers. We have organized the data by organ system for each AED for easier reference.
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Affiliation(s)
- Dean P Sarco
- Department of Neurology, Division of Epilepsy and Clinical Neurophysiology, Children's Hospital Boston, Boston, Massachusetts, USA.
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Stephen LJ, Kelly K, Wilson EA, Parker P, Brodie MJ. A prospective audit of adjunctive zonisamide in an everyday clinical setting. Epilepsy Behav 2010; 17:455-60. [PMID: 20207201 DOI: 10.1016/j.yebeh.2010.01.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2009] [Revised: 01/13/2010] [Accepted: 01/15/2010] [Indexed: 10/19/2022]
Abstract
This audit examined outcomes for 203 patients prescribed zonisamide (ZNS) for various uncontrolled seizure types at a specialist outpatient service. Forty-two (20.7%) patients achieved 6 months of seizure freedom, and an additional 37 (18.2%) had a 50% seizure reduction for 6 months on a stable ZNS dose. Seizure freedom was more likely in patients with primary generalized (24/61, 39%) than in those with partial-onset (18/141, 12.7%) seizures (P<0.001). Eight patients (5 seizure free) were maintained on ZNS monotherapy. More patients became seizure free with ZNS as monotherapy or first add-on, compared with those in whom ZNS was the second, third, or fourth adjunctive drug (P=0.001). Seizure freedom was less likely in patients treated with hepatic enzyme-inducing agents (13/113, 11.5%) than in those receiving noninducing AEDs (24/82, 29.3%) (P=0.002). ZNS was discontinued in 72 (35.5%) patients largely because of side effects (n=58, 28.6%). Commonest complaints leading to withdrawal were sedation (n=14), nausea and vomiting (n=13), neuropsychiatric symptoms (n=12), rash (n=6), and weight loss (n=6). Around 80% of patients who became seizure free on ZNS or had the drug withdrawn did so on a dose 200mg. ZNS is an effective broad-spectrum AED that can also produce a range of dose-dependent and idiosyncratic side effects.
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Affiliation(s)
- Linda J Stephen
- Epilepsy Unit, Division of Cardiovascular & Medical Sciences, Western Infirmary, Glasgow, Scotland, UK.
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Voltage-gated calcium channels in the etiopathogenesis and treatment of absence epilepsy. ACTA ACUST UNITED AC 2010; 62:245-71. [DOI: 10.1016/j.brainresrev.2009.12.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Revised: 12/10/2009] [Accepted: 12/11/2009] [Indexed: 12/21/2022]
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Effectiveness and tolerability of zonisamide in children with epilepsy: A retrospective review. Seizure 2010; 19:31-5. [DOI: 10.1016/j.seizure.2009.10.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2009] [Revised: 10/27/2009] [Accepted: 10/29/2009] [Indexed: 11/17/2022] Open
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Penovich PE, Willmore LJ. Use of a new antiepileptic drug or an old one as first drug for treatment of absence epilepsy. Epilepsia 2009; 50 Suppl 8:37-41. [PMID: 19702732 DOI: 10.1111/j.1528-1167.2009.02234.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Treatment of absence epilepsy requires understanding the efficacy and side effects of several drugs, one of which first became available more than 50 years ago. Methods for drug development and procedures for evaluating their safety and efficacy over that time have changed dramatically. Observational studies of the efficacy of ethosuximide, a drug developed in the 1950s, reported complete seizure control in 40-60% of patients. Valproic acid, a drug with a broad spectrum of effect, showed robust efficacy as well for control of absence seizures. Because side effects limit use in some patients, newer drugs were evaluated in patients with absence seizures. Of drugs becoming available in the last 15 years, lamotrigine has some effect in absence seizures. Although older and newer drugs presently are used without the rigorous underpinnings of the highest quality of evidence, our analysis found that ethosuximide, valproate, and lamotrigine are effective in the treatment of absence seizures, with ethosuximide quite possibly being the first drug of choice.
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Affiliation(s)
- Patricia E Penovich
- Minnesota Epilepsy Group PA, University of Minnesota School of Medicine, USA
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Montouris G, Abou-Khalil B. The first line of therapy in a girl with juvenile myoclonic epilepsy: Should it be valproate or a new agent? Epilepsia 2009; 50 Suppl 8:16-20. [DOI: 10.1111/j.1528-1167.2009.02230.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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Hughes JR. Absence seizures: a review of recent reports with new concepts. Epilepsy Behav 2009; 15:404-12. [PMID: 19632158 DOI: 10.1016/j.yebeh.2009.06.007] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Revised: 06/02/2009] [Accepted: 06/07/2009] [Indexed: 02/01/2023]
Abstract
Absence seizures with bilateral spike-wave (SW) complexes at 3Hz are divided into the childhood form, with onset at around 6 years of age, and the juvenile form, with onset usually at 12 years of age. These seizures typically last 9-12s and, at times, are activated by hyperventilation and occasionally by photic stimulation. Generalized tonic-clonic (GTC) seizures may also occur, especially in the juvenile form. There may be cognitive changes, in addition to linguistic and behavioral problems. Possible mechanisms for epileptogenesis may involve GABAergic systems, but especially T-calcium channels. The thalamus, especially the reticular nucleus, plays a major role, as does the frontal cortex, mainly the dorsolateral and orbital frontal areas, to the extent that some investigators have concluded that absence seizures are not truly generalized, but rather have selective cortical networks, mainly ventromesial frontal areas and the somatosensory cortex. The latter network is a departure from the more popular concept of a generalized epilepsy. Between the "centrencephalic" and "corticoreticular" theories, a "unified" theory is presented. Proposed genes include T-calcium channel gene CACNA1H, likely a susceptible gene in the Chinese Han population and a contributory gene in Caucasians. Electroencephalography has revealed an interictal increase in prefrontal activity, essential for the buildup of the ictal SW complexes maximal in that region. Infraslow activity can also be seen during ictal SW complexes. For treatment, counter to common belief, ethosuximide may not increase GTC seizures, as it reduces low-threshold T-calcium currents in thalamic neurons. Valproic acid and lamotrigine are also first-line medications. In addition, zonisamide and levetiracetam can be very helpful in absence epilepsy.
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Affiliation(s)
- John R Hughes
- Department of Neurology, University of Illinois Medical Center (M/C 796), 912 South Wood Street, Chicago, IL 60612, USA.
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Matar N, Jin W, Wrubel H, Hescheler J, Schneider T, Weiergräber M. Zonisamide block of cloned human T-type voltage-gated calcium channels. Epilepsy Res 2009; 83:224-34. [DOI: 10.1016/j.eplepsyres.2008.11.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2008] [Revised: 11/07/2008] [Accepted: 11/11/2008] [Indexed: 01/01/2023]
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Abstract
Antiepileptic drugs (AEDs) suppress seizures by selectively modifying the excitability of neurons and blocking seizure firing with minimal disturbance of nonepileptic activity. All AEDs have been shown to work by at least one of 3 main mechanisms of action: through modulation of voltage-gated ion channels, enhancement of synaptic inhibition, and inhibition of synaptic excitation. Zonisamide is a novel AED that has a broad combination of complementary mechanisms of action, which may offer a clinical advantage over other antiepileptic agents. By altering the fast inactivation threshold of voltage-dependent sodium channels, zonisamide reduces sustained high-frequency repetitive firing of action potentials. Zonisamide also inhibits low-threshold T-type calcium channels in neurons, which may prevent the spread of seizure discharge across cells. In addition, zonisamide is a weak inhibitor of carbonic anhydrase. However, this mechanism is not believed to contribute to the antiepileptic activity of zonisamide. Although zonisamide also seems to alter dopamine, serotonin, and acetylcholine metabolism, it is not clear to what extent these effects on neurotransmitters are involved in the clinical actions of the drug. In addition to these actions, recent evidence suggests that zonisamide may exert neuroprotective actions, independent of its antiepileptic activity. These potential effects may be important in preventing neuronal damage caused by recurrent seizures. Therefore, it seems that the multiple pharmacological actions of zonisamide may contribute to the seizure reductions observed in a wide range of epilepsies and may help to preserve efficacy in individual patients despite possible changes in electrophysiological status.
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Affiliation(s)
- Victor Biton
- Arkansas Epilepsy Program, Little Rock, AR, USA.
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Abstract
Zonisamide is a modern antiepileptic drug (AED) that is distinguished from other AEDs by its unique structure and broad mechanistic profile. Preclinical studies have reported a range of potential mechanisms of action for zonisamide, such as blocking voltage-gated sodium channels, reduction of T-type calcium channel currents, and enhancement of gamma-aminobutyric acid (GABA)-mediated inhibition, which are indicative of its broad antiseizure effects. Zonisamide has a favorable linear pharmacokinetic profile, a long half-life, and a low incidence of protein-binding interactions with other AEDs. Hepatically metabolized through the cytochrome P450 pathway, zonisamide does not induce its own metabolism or liver enzymes. For more than 2 decades, zonisamide has been extensively used as monotherapy and adjunctive therapy for the treatment of partial and generalized seizures in pediatric and adult patients in Japan. Zonisamide was approved in the USA in 2000 as adjunctive therapy for partial seizures in adults. With over 2 million patient-years of exposure internationally, zonisamide has demonstrated safety and efficacy against a multitude of epilepsy and seizure types, including both partial and generalized seizures. This review focuses on the experience and use of zonisamide in partial seizures, as well as possible new uses for zonisamide.
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Abstract
This review discusses current pharmacological treatment of childhood absence epilepsy (CAE). The key to successful treatment is the correct diagnosis of the epileptic syndrome, hence the initial part of the paper discusses the definition, diagnostic criteria and epidemiology. This is followed by a detailed analysis of pharmacological agents used in the treatment of CAE. The characteristics of old and new anticonvulsants used in the treatment of CAE are also reviewed. For each of the drugs, the mechanism of action, usual dose, common side effects and recommendations for treatment are also discussed. A separate section focuses on instances when anticonvulsants may exacerbate seizures. Particular emphasis is given to the evidence currently available, on which clinical practice needs to be based.
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Affiliation(s)
- Ewa Posner
- University Hospital of North Durham, Department of Paediatrics, North Road Durham, DH1 5TW, UK.
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Yoshida S, Okada M, Zhu G, Kaneko S. Effects of zonisamide on neurotransmitter exocytosis associated with ryanodine receptors. Epilepsy Res 2005; 67:153-62. [PMID: 16289509 DOI: 10.1016/j.eplepsyres.2005.10.001] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2005] [Revised: 09/30/2005] [Accepted: 10/02/2005] [Indexed: 11/16/2022]
Abstract
To clarify the antiepileptic and neuroprotective actions of zonisamide (ZNS), we determined acute effects of ZNS on exocytosis of GABA and glutamate associated with ryanodine-receptor (Ryr) in rat hippocampus using microdialysis. ZNS increased basal GABA release concentration-dependently without affecting basal glutamate release; however, K(+)-evoked glutamate and GABA releases were reduced by ZNS concentration-dependently. Inhibition of Ryr reduced K(+)-evoked GABA and glutamate releases without affecting their basal releases. Ryanodine affected GABA and glutamate releases biphasic concentration-dependently: lower concentration of ryanodine increased both basal and K(+)-evoked releases of GABA and glutamate, whereas higher concentration reduced them. The therapeutically relevant concentration of ZNS inhibited ryanodine-induced GABA and glutamate releases, and abolished the inflection point in concentration-response curve for ryanodine on neurotransmitter exocytosis. These data suggest that ZNS elevates seizure threshold via enhancement of GABAergic transmission during resting stage. ZNS inhibits propagation of epileptic hyperexcitability and Ryr-associated neuronal damage during neuronal hyperexcitable stage. These demonstrations indicate that the indirect inhibition of Ryr activities by ZNS during neuronal hyperexcitability appear to be involved in the mechanisms of action of antiepileptic and neuroprotective actions of ZNS.
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Affiliation(s)
- Shukuko Yoshida
- Department of Neuropsychiatry, Hirosaki University, Hirosaki 036-8562, Japan
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Abstract
The idiopathic generalized epilepsies (IGE) are a group of epilepsies that are genetically determined, have no structural or anatomic cause, and usually begin early in life. Neurologic examination, intelligence, and imaging studies are normal, and EEG shows only epileptiform abnormalities (i.e., no abnormal slow activity or evidence for diffuse encephalopathy). In some IGE, the genetic substrate has been identified, whereas in most, it remains unknown. Depending on the age at onset and predominant seizure type, individual subtypes of IGE (syndromes) are defined. However, overall, there are more similarities than there are differences among the various subtypes, and the IGE are best viewed as a spectrum or continuum of conditions. In general, IGE respond to treatment, with 80-90% becoming fully controlled. However, not all antiepileptic drugs (AED) are equally effective in IGE. Some AED are ill advised because they either do not work or exacerbate seizure types other than generalized tonic-clonic (GTC) seizures, that is, absence and myoclonic seizures. These include carbamazepine, oxcarbazepine, phenytoin, gabapentin, and tiagabine. Their use is the main cause of "pseudo-intractability," and at least in the United States where PHT and CBZ are the most commonly used AEDs, patients with IGE are often on inadequate medications. For patients with clear IGE, the drug of choice is generally valproic acid because it effectively controls absence myoclonic seizures and GTC seizures. Second-line drugs (when first-line drugs fail or are not tolerated) may include benzodiazepines, but the use of second-line drugs is evolving rapidly. Some of the newer AEDs are considered broad spectrum, meaning that they work in IGE and focal epilepsies, although the evidence is largely preliminary at this point. These newer AEDs include lamotrigine, topiramate, levetiracetam, and zonisamide.
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Affiliation(s)
- Selim R Benbadis
- Department of Neurology , University of South Florida, Tampa General Hospital, Tampa, Florida 33606, USA.
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Bergey GK. Evidence-based Treatment of Idiopathic Generalized Epilepsies with New Antiepileptic Drugs. Epilepsia 2005; 46 Suppl 9:161-8. [PMID: 16302891 DOI: 10.1111/j.1528-1167.2005.00328.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
With the introduction of over ten new antiepileptic drugs (AEDs) since 1993, the hope has been that at least some of these agents would be useful for not just partial seizures, but also for the primary generalized seizures of the idiopathic generalized epilepsies (IGE). The development of evidence-based treatment guidelines in the IGE, however, faces a number of challenges, particularly after an antiepileptic drug (AED) receives approval for one indication. The majority of patients with IGE are controlled with first-line therapy if appropriately selected. Case reports or series typically appear with use in refractory patients, but these studies lack the rigor to allow formulation of guidelines. Still we are beginning to see some good class I and II data to support use of selected second-generation AEDs. It is postulated that lamotrigine (LTG), levetiracetam (LEV), topiramate (TPM), and zonisamide (ZSM) may have efficacy for a broad spectrum of seizure types including those of IGE. At the present time good class I and II evidence exists to support the use of LTG for typical absence, LEV for idiopathic myoclonic seizures, and TPM for primary generalized tonic-clonic seizures, even though only TPM has FDA approval for primary generalized seizures. This article examines the available rigorous evidence that can support these uses and also discusses some selected other reports that suggest a spectrum of efficacy for these new agents.
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Affiliation(s)
- Gregory K Bergey
- Department of Neurology, Johns Hopkins Epilepsy Center, Johns Hopkins University, School of Medicine and Hospital, Baltimore, Maryland 21287, USA.
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