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Zhang H, Ou Z, Zhang E, Liu W, Hao N, Chen Y, Liu Y, Ye H, Zhou D, Wu X. Efficacy and safety of add-on antiseizure medications for focal epilepsy: A network meta-analysis. Epilepsia Open 2024; 9:1550-1564. [PMID: 38888005 PMCID: PMC11296132 DOI: 10.1002/epi4.12997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/26/2024] [Accepted: 06/04/2024] [Indexed: 06/20/2024] Open
Abstract
OBJECTIVE Several antiseizure medications (ASMs) have been approved for the treatment of focal epilepsy. However, there is a paucity of evidence on direct comparison of ASMs. We evaluated the comparative efficacy and safety of all approved add-on ASMs for the treatment of focal epilepsy using network meta-analysis. METHODS Data through extensive literature search was retrieved from PubMed, Embase, Cochrane, and ClinicalTrial.gov databases using predefined search terms from inception through March 2023. PRISMA reporting guidelines (CRD42023403450) were followed in this study. Efficacy outcomes assessed were ≥50%, ≥75%, and 100% responder rates. Patient retention rate and safety outcomes such as overall treatment-emergent adverse events (TEAEs) and individual TEAEs were assessed. "Gemtc" 4.0.4 package was used to perform Bayesian analysis. Outcomes are reported as relative risks (RRs) and 95% confidence interval (CI). RESULTS Literature search retrieved 5807 studies of which, 75 studies were included in the analysis. All ASMs showed significantly higher ≥50% responder rate compared with placebo. Except the ≥75% seizure frequency reduction for zonisamide (2.23; 95% CI: 1.00-5.70) and 100% for rufinamide (2.03; 95% CI: 0.54-11.00), all other interventions showed significantly higher ≥75% and 100% responder rates compared with placebo. Among treatments, significantly higher 100% responder rate was observed with cenobamate compared to eslicarbazepine (10.71; 95% CI: 1.56-323.9) and zonisamide (10.63; 95% CI: 1.37-261.2). All ASMs showed a lower patient retention rate compared to placebo, with the least significant value observed for oxcarbazepine (0.77; 95% CI: 0.7-0.84). Levetiracetam showed a lower risk of incidence (1.0; 95%CI: 0.94-1.1; SUCRA: 0.885067) for overall TEAE compared with other medications. SIGNIFICANCE All approved ASMs were effective as add-on treatment for focal epilepsy. Of the ASMs included, cenobamate had the greatest likelihood of allowing patients to attain seizure freedom. PLAIN LANGUAGE SUMMARY This article compares the efficacy and safety of antiseizure medications (ASMs) currently available to neurologists in the treatment of epileptic patients. Several newer generation ASMs that have been developed may be as effective or better than the older medications. We included 75 studies in the analysis. In comparison, all drugs improved ≥50%, ≥75% and 100% responder rates compared to control, except for Zonisamide and Rufinamide in the ≥75% and 100% responder rate categories. Retention of patients undergoing treatment was lower in drugs than placebo. All drugs were tolerated, the levetiracetam showed the best tolerability. Cenobamate more likely help completely to reduce seizures.
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Affiliation(s)
- Hesheng Zhang
- Neurology DepartmentWest China Hospital of Sichuan UniversityChengduSichuanChina
| | - Zhujing Ou
- Neurology DepartmentWest China Hospital of Sichuan UniversityChengduSichuanChina
| | - Enhui Zhang
- Neurology DepartmentWest China Hospital of Sichuan UniversityChengduSichuanChina
| | - Wenyu Liu
- Neurology DepartmentWest China Hospital of Sichuan UniversityChengduSichuanChina
| | - Nanya Hao
- Neurology DepartmentWest China Hospital of Sichuan UniversityChengduSichuanChina
| | - Yujie Chen
- Neurology DepartmentWest China Hospital of Sichuan UniversityChengduSichuanChina
| | - Yutong Liu
- Ignis Therapeutics (Shanghai) LimitedShanghaiChina
| | - Hui Ye
- Ignis Therapeutics (Shanghai) LimitedShanghaiChina
| | - Dong Zhou
- Neurology DepartmentWest China Hospital of Sichuan UniversityChengduSichuanChina
| | - Xintong Wu
- Neurology DepartmentWest China Hospital of Sichuan UniversityChengduSichuanChina
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Sancetta BM, Ricci L, Lanzone J, Boscarino M, Narducci F, Lippa G, Nesta M, Di Lazzaro V, Tombini M, Assenza G. Overnight switch from carbamazepine to eslicarbazepine in a real-life clinical scenario: a retrospective study. Neurol Sci 2024; 45:3435-3442. [PMID: 38315252 DOI: 10.1007/s10072-024-07354-6] [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: 12/01/2023] [Accepted: 01/22/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Carbamazepine (CBZ) is a first-choice anti-seizure medication (ASM) whose efficacy is often invalidated by adverse effects (AEs). Eslicarbazepine (ESL) is a structural derivative of CBZ with better pharmacokinetic/tolerability profiles. We describe our experience of the overnight CBZ to ESL switch in people with epilepsy (PwE) to improve seizure control, AEs, and ASMs adherence. METHODS We retrospectively included 19 PwE (12 females, 53 ± 21 years old) who underwent CBZ to ESL overnight switch due to single/multiple issues: poor efficacy (pEff, N = 8, 42%), tolerability (pToll, N = 11, 58%), adherence (pAdh, N = 2, 10%). 9/19 (47%) had psychiatric comorbidities. Clinical variables, seizure frequency, and AEs were recorded at switch time (T0) after 3.5 ± 3 (T1) and 6.5 ± 1.5 months (T2). RESULTS At T1, in pEff group, 1/8 (13%) was seizure free, 2/8 (25%) were responders (> 50% seizure reduction), 2/8 (25%) had no seizure changes, 3/8 (37%) had seizure worsening; the latter were those with the most severe epilepsy and encephalopathy. In pToll group, all PwE experienced AEs disappearance/amelioration. In pAdh group, all PwE reported adherence amelioration. Four dropouts. At T2, no changes were recorded within groups, while in the whole sample, 6/15 (40%) were responders, and 4/15 (27%) were seizure-free. No one complained of Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation psychiatric worsening, while 6/19 (32%) experienced mood/behavior benefits. CONCLUSIONS CBZ to ESL overnight switch offers an opportunity to improve efficacy, tolerability, adherence, and psychiatric symptoms.
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Affiliation(s)
- Biagio Maria Sancetta
- UOC Neurologia, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy.
- Research Unit of Neurology, Neurophysiology and Neurobiology, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy.
| | - Lorenzo Ricci
- UOC Neurologia, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
- Research Unit of Neurology, Neurophysiology and Neurobiology, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
| | - Jacopo Lanzone
- Istituti Clinici Scientifici Maugeri IRCCS, Neurorehabilitation Department of the Milano Institute, Milan, Italy
| | - Marilisa Boscarino
- Istituti Clinici Scientifici Maugeri IRCCS, Neurorehabilitation Department of the Milano Institute, Milan, Italy
| | - Flavia Narducci
- UOC Neurologia, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
- Research Unit of Neurology, Neurophysiology and Neurobiology, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
| | - Giulia Lippa
- UOC Neurologia, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
- Research Unit of Neurology, Neurophysiology and Neurobiology, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
| | - Marianna Nesta
- UOC Neurologia, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
- Research Unit of Neurology, Neurophysiology and Neurobiology, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
| | - Vincenzo Di Lazzaro
- UOC Neurologia, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
- Research Unit of Neurology, Neurophysiology and Neurobiology, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
| | - Mario Tombini
- UOC Neurologia, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
- Research Unit of Neurology, Neurophysiology and Neurobiology, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
| | - Giovanni Assenza
- UOC Neurologia, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
- Research Unit of Neurology, Neurophysiology and Neurobiology, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
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Aurlien DB, Taubøll E. Antiseizure medication and SUDEP - a need for unifying methodology in research. Front Neurol 2024; 15:1385468. [PMID: 38694773 PMCID: PMC11061368 DOI: 10.3389/fneur.2024.1385468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 04/03/2024] [Indexed: 05/04/2024] Open
Abstract
The risk of sudden unexpected death in epilepsy (SUDEP) increases with the frequency of generalized tonic-clonic seizures. Carbamazepine (CBZ) and lamotrigine (LTG) have been suggested to increase the risk. However, the prevailing viewpoint is that the choice of antiseizure medication (ASM) does not influence the occurrence. We have explored the approach to addressing this question in relevant studies to evaluate the validity of the conclusions reached. A systematic search was performed in PubMed to identify all controlled studies on SUDEP risk in individuals on CBZ or LTG. Studies were categorized according to whether idiopathic generalized epilepsy (IGE) or females were considered separately, and whether data were adjusted for seizure frequency. Eight studies on CBZ and six studies on LTG were identified. For CBZ, one study showed a significantly increased risk of SUDEP without adjustment for seizure frequency. Another study found significantly increased risk after statistical adjustment for seizure frequency and one study found increased risk with high blood levels. Five other studies found no increase in risk. For LTG, one study showed a significantly increased risk in patients with IGE as opposed to focal epilepsy, and another study showed a significantly increased risk in females. None of the subsequent studies on LTG and none of the studies on CBZ considered females with IGE separately. Taken together the available studies suggest that LTG, and possibly CBZ, may increase occurrence of SUDEP when used in females with IGE. Additional studies with sub-group analysis of females with IGE are needed.
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Affiliation(s)
- Dag Bruheim Aurlien
- Neuroscience Research Group and Department of Neurology, Stavanger University Hospital, Stavanger, Norway
| | - Erik Taubøll
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
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Gatson TN, Freemont OA, Coleman RL, Lockett SJ, Spillers NJ, Ahmadzadeh S, Viswanath O, Varrassi G, Shekoohi S, Kaye AD. Vigabatrin (Sabril) for the Treatment of Refractory Complex Focal Seizures in Adults: Pharmacologic and Clinical Considerations. Cureus 2023; 15:e46414. [PMID: 37927747 PMCID: PMC10621625 DOI: 10.7759/cureus.46414] [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: 08/08/2023] [Accepted: 10/03/2023] [Indexed: 11/07/2023] Open
Abstract
To review the pharmacokinetics, efficacy, and adverse effects of vigabatrin (Sabril) and its role in managing refractory focal unaware seizures in adults. In the present investigation, a search of English-language literature from 1999 through 2023 was conducted using vigabatrin and Sabril as search terms to identify relevant studies and review articles. A 2000 double-blind, placebo-controlled multicenter study found that out of 90 adult patients, 48% of those treated with vigabatrin achieved a 50% or greater reduction in the frequency of complex partial seizures, compared to 26% of placebo-treated patients. This study also observed that vigabatrin was well tolerated by 72.4% of patients, with the most common side effects being drowsiness, dizziness, headache, and fatigue. Further studies with a significant risk of vigabatrin-associated visual field loss necessitate vigabatrin only being an option for refractory cases. Additional studies suggest that despite the potential risk of vision loss and adverse effects, adult patients continue to use vigabatrin long-term. Sabril is an antiepileptic medication prescribed as an additional treatment for refractory complex partial seizures in patients at least ten years old who have not responded well to other alternative therapies. Multiple clinical trials indicate that Sabril sufficiently reduces the frequency of seizures when used as an adjunct treatment of refractory complex focal seizures. However, it is important to carefully monitor patients for any adverse effects, particularly long-term use, and to discontinue the drug if serious side effects occur.
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Affiliation(s)
- Taylor N Gatson
- Medicine, Louisiana State University Health Sciences Center at Shreveport, Shreveport, USA
| | - Orlandria A Freemont
- Medicine, Louisiana State University Health Sciences Center at Shreveport, Shreveport, USA
| | - Rachel L Coleman
- Medicine, Louisiana State University Health Sciences Center at Shreveport, Shreveport, USA
| | - Stewart J Lockett
- Medicine, Louisiana State University Health Sciences Center at Shreveport, Shreveport, USA
| | - Noah J Spillers
- Medicine, Louisiana State University Health Sciences Center at Shreveport, Shreveport, USA
| | - Shahab Ahmadzadeh
- Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, USA
| | - Omar Viswanath
- Pain Management, Valley Pain Consultants - Envision Physician Services, Phoenix, USA
| | | | - Sahar Shekoohi
- Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, USA
| | - Alan D Kaye
- Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, USA
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Cheraghmakani H, Rezapour M, Asghari F, Alizadeh-Navaei R, Ghazaeian M, Tabrizi N. Pyridoxine for treatment of levetiracetam-induced behavioral adverse events: A randomized double-blind placebo-controlled trial. Epilepsy Behav 2022; 136:108938. [PMID: 36228485 DOI: 10.1016/j.yebeh.2022.108938] [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: 05/05/2022] [Revised: 09/27/2022] [Accepted: 09/27/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Levetiracetam is a broad-spectrum antiseizure medication with known behavioral side effects. The possible beneficial effect of pyridoxine on improvement of these psychiatric problems has been suggested in few previous studies. This clinical trial aimed to investigate the effect of pyridoxine on behavioral side effects of levetiracetam in adult patients with epilepsy. METHODS This study was a randomized double-blind placebo-controlled clinical trial on 53 adult patients with epilepsy with behavioral side effects after treatment by levetiracetam. Patients who met the study criteria were randomized to receive 40 mg/day pyridoxine or placebo. Their psychiatric state was surveyed by SCL-90-R questionnaire before and three weeks after initiation of treatment. RESULTS There were no statistically significant differences in the behavioral adverse effects between the pyridoxine-treated group and the placebo group. CONCLUSION Although this study showed no statistically significant beneficial effects of pyridoxine on the behavioral adverse effects of levetiracetam, placebo-controlled trials with a larger size and higher doses are needed to determine whether it is effective or not.
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Affiliation(s)
- Hamed Cheraghmakani
- Neurology Department, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Maryam Rezapour
- Psychiatry and Behavioural Sciences Research Center, Addiction Institute, Department of Psychiatry, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Faezeh Asghari
- Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Reza Alizadeh-Navaei
- Gastrointestinal Cancer Research Center, Non-communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Monireh Ghazaeian
- Pharmaceutical Research Center, Department of Clinical Pharmacy, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Nasim Tabrizi
- Neurology Department, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.
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Busl KM, Fong MWK, Newcomer Z, Patel M, Cohen SA, Jadav R, Smith CN, Mitropanopoulos S, Bruzzone M, Hella M, Eisenschenk S, Robinson CP, Roth WH, Ameli PA, Babi MA, Pizzi MA, Gilmore EJ, Hirsch LJ, Maciel CB. Pregabalin for Recurrent Seizures in Critical Illness: A Promising Adjunctive Therapy, Especially for cyclic Seizures. Neurocrit Care 2022; 37:140-148. [PMID: 35217998 DOI: 10.1007/s12028-022-01459-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/27/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Pregabalin (PGB) is an effective adjunctive treatment for focal epilepsy and acts by binding to the alpha2-delta subunit of voltage-gated calcium channels to reduce excitatory neurotransmitter release. Limited data exist on its use in the neurocritical care setting, including cyclic seizures-a pattern of recurrent seizures occurring at nearly regular intervals. Although the mechanism underpinning cyclic seizures remains elusive, spreading excitation linked to spreading depolarizations may play a role in seizure recurrence and periodicity. PGB has been shown to increase spreading depolarization threshold; hence, we hypothesized that the magnitude of antiseizure effect from PGB is more pronounced in patients with cyclic versus noncyclic seizures in a critically ill cohort with recurrent seizures. METHODS We conducted a retrospective case series of adults admitted to two academic neurointensive care units between January 2017 and March 2019 who received PGB for treatment of seizures. Data collected included demographics, etiology of brain injury, antiseizure medications, and outcome. Continuous electroencephalogram recordings 48 hours before and after PGB administration were reviewed by electroencephalographers blinded to the administration of antiseizure medications to obtain granular data on electrographic seizure burden. Cyclic seizures were determined quantitatively (i.e., < 50% variation of interseizure intervals for at least 50% of consecutive seizures). Coprimary outcomes were decrease in hourly seizure burden in minutes and decrease in seizure frequency in the 48 hours after PGB initiation. We used nonparametric tests for comparison of seizure frequency and burden and segmented linear regression to assess PGB effect. RESULTS We included 16 patients; the median age was 69 years, 11 (68.7%) were women, three (18.8%) had undergone a neurosurgical procedure, and five (31%) had underlying epilepsy. All seizures had focal onset; ten patients (62.5%) had cyclic seizures. The median hourly seizure burden over the 48 hours prior to PGB initiation was 1.87 min/hour (interquartile range 1.49-8.53), and the median seizure frequency was 1.96 seizures/hour (interquartile range 1.06-3.41). In the 48 hours following PGB (median daily dose 300 mg, range 75-300 mg), the median number of seizures per hour was reduced by 0.80 seizures/hour (95% confidence interval 0.19-1.40), whereas the median hourly seizure burden decreased by 1.71 min/hour (95% confidence interval 0.38-3.04). When we compared patients with cyclic versus noncyclic seizures, there was a relative decrease in hourly seizure frequency (- 86.7% versus - 2%, p = 0.04) and hourly seizure burden (- 89% versus - 7.8%, p = 0.03) at 48 hours. CONCLUSIONS PGB was associated with a relative reduction in seizure burden in neurocritically ill patients with recurrent seizures, especially those with cyclic seizures, and may be considered in the therapeutic arsenal for refractory seizures. Whether this effect is mediated via modulation of spreading depolarization requires further study.
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Affiliation(s)
- Katharina M Busl
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Michael W K Fong
- Westmead Comprehensive Epilepsy Unit, Westmead Hospital, University of Sydney, Sydney, Australia.,Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | | | - Mitesh Patel
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Scott A Cohen
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Rakesh Jadav
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Christine N Smith
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | | | - Maria Bruzzone
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | | | - Stephan Eisenschenk
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Christopher P Robinson
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - William H Roth
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Pouya Alexander Ameli
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Marc-Alain Babi
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Michael A Pizzi
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Emily J Gilmore
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Carolina B Maciel
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA. .,Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA. .,Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA. .,Department of Neurology, University of Utah, Salt Lake City, UT, 81432, USA. .,Neurocritical Care, McKnight Brain Institute, 1149 Newell Drive, L3-100, Gainesville, FL, 32610, USA.
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Privitera M, Richy FF, Schabert VF. Indirect treatment comparison of cenobamate to other ASMs for the treatment of uncontrolled focal seizures. Epilepsy Behav 2022; 126:108429. [PMID: 34864380 DOI: 10.1016/j.yebeh.2021.108429] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/05/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The efficacy and safety of cenobamate relative to other antiseizure medications (ASMs) has not been evaluated. An indirect treatment comparison (network meta-analysis) was performed to determine if adjunctive cenobamate increases the odds ratio (OR) for ≥50% responder rate or for withdrawals due to treatment-emergent adverse events (TEAEs) leading to ASM discontinuation versus adjunctive therapy with other ASMs. METHODS A systematic literature review was conducted to identify randomized, double-blind, placebo-controlled trials (maintenance phase ≥ 12 weeks) assessing adjunctive ASMs in adults with uncontrolled focal seizures. Cenobamate was compared to a group of seven other ASMs, and to subgroups of branded (brivaracetam, eslicarbazepine acetate, lacosamide, and perampanel) and older (lamotrigine, levetiracetam, and topiramate) ASMs at FDA-recommended daily maintenance doses (FDA-RDMD), at all doses, and at maximum and minimum daily doses. Statistical significance was set at p < 0.05. RESULTS Twenty-one studies were eligible for analysis. The placebo-adjusted ≥ 50% responder rate for FDA-RDMD of cenobamate was superior (OR 4.200; 95% CI 2.279, 7.742) to FDA-RDMD of all seven assessed (OR 2.202 95% CI 1.915, 2.532; p = 0.044) and branded ASMs (OR 2.148; 95% CI 1.849, 2.494; p = 0.037). There was no significant difference for ≥50% responder rate between FDA-RDMD of cenobamate and FDA-RDMD of older ASMs (OR 2.617; 95% CI 1.767, 3.878; p = 0.202). No significant differences were identified for ≥50% responder rate when comparing all doses and maximum/minimum doses of cenobamate to all seven, branded, and older ASMs. Cenobamate demonstrated comparable TEAE withdrawal rates to all seven ASMs, branded ASMs, and older ASMs across each of the four dose ranges (all p > 0.05). SIGNIFICANCE Patients receiving FDA-RDMD of cenobamate were more likely to have ≥50% seizure reduction compared with FDA-RDMD of the seven assessed ASMs and branded ASMs, without an increase in treatment discontinuation due to TEAEs.
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Affiliation(s)
- Michael Privitera
- Epilepsy Center, University of Cincinnati Gardner Neuroscience Institute, Cincinnati, OH, USA.
| | - Florent F Richy
- BluePoint Consulting SCS, Liege, Belgium; University of Liege, Faculty of Medicine, Liege, Belgium
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Synergistic Effect of Perampanel and Temozolomide in Human Glioma Cell Lines. J Pers Med 2021; 11:jpm11050390. [PMID: 34068749 PMCID: PMC8150827 DOI: 10.3390/jpm11050390] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/03/2021] [Accepted: 05/06/2021] [Indexed: 12/23/2022] Open
Abstract
Glioblastoma is characterized by a high proliferative rate and drug resistance. The standard of care includes maximal safe surgery, followed by radiotherapy and temozolomide chemotherapy. The expression of glutamate receptors has been previously reported in human glioma cell lines. The aim of this study was to examine the cellular effects of perampanel, a broad-spectrum antiepileptic drug acting as an α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPA) glutamate receptor antagonist, alone or in combination with temozolomide. Four human glioma cell lines were exposed to different concentrations of perampanel and temozolomide, alone or in combination. The type of drug interaction was assessed using the Chou-Talalay method. Apoptosis, cell cycle perturbation, and glutamate receptors (GluRs) subunit expression were assessed by flow cytometry. Perampanel significantly inhibited the growth, inducing high levels of apoptosis. A strong synergistic effect of the combination of perampanel with temozolomide was detected in U87 and A172, but not in U138. Treatment with perampanel resulted in an increased GluR2/3 subunit expression in U87 and U138. Perampanel displays a pro-apoptotic effect on human glioblastoma cell lines when used alone, possibly due to increased GluR2/3 expression. The observed synergistic effect of the combination of temozolomide with perampanel suggests further investigation on the impact of this combination on oncologic outcomes in glioblastoma.
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Rahim F, Azizimalamiri R, Sayyah M, Malayeri A. Experimental Therapeutic Strategies in Epilepsies Using Anti-Seizure Medications. J Exp Pharmacol 2021; 13:265-290. [PMID: 33732031 PMCID: PMC7959000 DOI: 10.2147/jep.s267029] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 02/10/2021] [Indexed: 02/02/2023] Open
Abstract
Epilepsies are among the most common neurological problems. The disease burden in patients with epilepsy is significantly high, and epilepsy has a huge negative impact on patients' quality of life with epilepsy and their families. Anti-seizure medications are the mainstay treatment in patients with epilepsy, and around 70% of patients will ultimately control with a combination of at least two appropriately selected anti-seizure medications. However, in one-third of patients, seizures are resistant to drugs, and other measures will be needed. The primary goal in using experimental therapeutic medication strategies in patients with epilepsy is to prevent recurrent seizures and reduce the rate of traumatic events that may occur during seizures. So far, various treatments using medications have been offered for patients with epilepsies, which have been classified according to the type of epilepsy, the effectiveness of the medications, and the adverse effects. Medications such as Levetiracetam, valproic acid, and lamotrigine are at the forefront of these patients' treatment. Epilepsy surgery, neuro-stimulation, and the ketogenic diet are the main measures in patients with medication-resistant epilepsies. In this paper, we will review the therapeutic approach using anti-seizure medications in patients with epilepsy. However, it should be noted that some of these patients still do not respond to existing treatments; therefore, the limited ability of current therapies has fueled research efforts for the development of novel treatment strategies. Thus, it seems that in addition to surgical measures, we should look for more specific agents that have less adverse events and have a greater effect in stopping seizures.
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Affiliation(s)
- Fakher Rahim
- Molecular Medicine and Bioinformatics, Research Center of Thalassemia & Hemoglobinopathy, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Reza Azizimalamiri
- Department of Pediatrics, Division of Pediatric Neurology, Golestan Medical, Educational, and Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mehdi Sayyah
- Education Development Center (EDC), Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Alireza Malayeri
- Medicinal Plant Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- Department of Pharmacology, School of Pharmacy, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Lanzone J, Boscarino M, Ricci L, Insola A, Tombini M, Di Lazzaro V, Assenza G. Effects of the noncompetitive AMPA receptor antagonist perampanel on thalamo-cortical excitability: A study of high-frequency oscillations in somatosensory evoked potentials. Clin Neurophysiol 2021; 132:1049-1056. [PMID: 33743300 DOI: 10.1016/j.clinph.2020.12.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 12/20/2020] [Accepted: 12/23/2020] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Wedesignedalongitudinalcohortstudyon People with Epilepsy (PwE) with the aimofassessingthe effect of Perampanel (PER) oncortico-subcortical networks, as measured by high-frequency oscillations of somatosensory evoked potentials (SEP-HFOs). SEP-HFOs measure the excitability of both thalamo-corticalprojections(early HFOs) and intracortical GABAergic synapses (late HFOs), thus they could be used to study the anti-glutamatergic action of PER, a selective antagonist of the AMPA receptor. METHODS 15 PwE eligible for PER add-on therapy, were enrolled prospectively. Subjects underwent SEPs recording from the dominant hand at two times: PwET0 (baseline, before PER titration) and PwET1 (therapeutic dose of 4 mg). HFOs were obtained by filtering N20 scalp response in the 400-800 Hz range. Patients were compared with a normative population of 15 healthy controls (HC) matched for age and sex. RESULTS We found a significant reduction ofTotal HFOs and mostly early HFOs area between PwET0 and PwET1 (p = 0.05 and p = 0.045 respectively) and between HC and PwET1 (p = 0.01). Furthermore, we found a significant reduction of P24/N24 Amplitude between PwET0 and HC and between PwET0 and PwET1 (p = 0.006 and p = 0.032, respectively). CONCLUSIONS Introduction of PER as add-on therapy reduced the area of total HFOs, acting mainly on the early burst, related to thalamo-cortical pathways. Furthermore P24/N24 amplitude, which seems to reflect a form of cortico-subcortical integration, resulted increased in PwE at T0 and normalized at T1. SIGNIFICANCE Our findings suggest that PER acts on cortico-subcortical excitability. This could explain the broad spectrum of PER and its success in forms of epilepsy characterized by thalamo-cortical hyperexcitability.
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Affiliation(s)
- Jacopo Lanzone
- Neurology, Neurophysiology and Neurobiology Unit, Department of Medicine, Università Campus Bio-Medico di Roma, Rome, Italy.
| | - Marilisa Boscarino
- Neurology, Neurophysiology and Neurobiology Unit, Department of Medicine, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Lorenzo Ricci
- Neurology, Neurophysiology and Neurobiology Unit, Department of Medicine, Università Campus Bio-Medico di Roma, Rome, Italy
| | | | - Mario Tombini
- Neurology, Neurophysiology and Neurobiology Unit, Department of Medicine, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Vincenzo Di Lazzaro
- Neurology, Neurophysiology and Neurobiology Unit, Department of Medicine, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Giovanni Assenza
- Neurology, Neurophysiology and Neurobiology Unit, Department of Medicine, Università Campus Bio-Medico di Roma, Rome, Italy
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Wheless JW. Adjunctive cenobamate for the treatment of focal onset seizures in adults with epilepsy: a critical review. Expert Rev Neurother 2020; 20:1085-1098. [DOI: 10.1080/14737175.2020.1834855] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- James W. Wheless
- Division of Pediatric Neurology, University of Tennessee Health Science Center; Le Bonheur Comprehensive Epilepsy Program & Neuroscience Institute, Memphis, TN, USA
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12
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Osuntokun OS, Akinsomisoye SO, Olayiwola G, Adedokun KI, Oladokun OO. Carbamazepine adversely altered the pituitary-testicular axis with resultant reproductive dysfunctions than levetiracetam or carbamazepine-levetiracetam adjuvant treatment in male Wistar rat. Andrologia 2020; 52:e13871. [PMID: 33126292 DOI: 10.1111/and.13871] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/06/2020] [Accepted: 09/16/2020] [Indexed: 12/12/2022] Open
Abstract
This study investigated the on-toward reactions of individual or adjunctive treatment with carbamazepine (CBZ) and levetiracetam (LEV) on the pituitary-testicular axis in male rats. Twenty-four male Wistar rats were randomised into 4 groups (n = 6) and received daily intraperitoneal (i.p) treatment of normal saline (0.1 ml/day); CBZ (25 mg/kg i.p); LEV (50 mg/kg i.p); or combination of CBZ (12.5 mg/kg) and LEV (25 mg/kg) for 4 weeks. The serum concentration of luteinising hormone (LH), follicle-stimulating hormone (FSH), and testosterone was determined. Also, the seminal profile and histomorphological status of the testis were determined. Data were analysed using descriptive and inferential statistics. The control and test groups were compared using Student's t test, analysis of variance (ANOVA), and Student-Newman-Keuls post hoc analysis where appropriate, while the results presented as mean ± SEM in graphs or tables. The level of significance was taken at p < .05. The percentage motility, viability, and concentration of FSH decreased significantly in all the treatment groups, while the testis was presented with various forms of histomorphological aberrations. This study concludes that CBZ, and CBZ + LEV adjunctive treatments alter the pituitary-testicular axis with evidence of hormonal deregulation and alteration in the reproductive functions' indices, while LEV treatment remains the safest.
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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
| | - Stephen Olumide Akinsomisoye
- Department of Physiological Sciences, Faculty of Basic Medical Sciences, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Gbola Olayiwola
- Department of Clinical Pharmacy and Pharmacy Administration, Faculty of Pharmacy Obafemi, Awolowo University, Ile-Ife, Nigeria
| | - Kabiru Isola Adedokun
- Department of Physiology, 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
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Abstract
Eslicarbazepine acetate (Zebinix®), a voltage-gated sodium channel blocker, is a once-daily, orally administered anti-seizure medication available in the EU for use as monotherapy in adults with newly diagnosed focal-onset seizures and as adjunctive therapy in adults, adolescents and children aged > 6 years with focal-onset seizures. In adult patients, adjunctive eslicarbazepine acetate was generally associated with a significant decrease in seizure frequency and an increase in responder rate compared with placebo. The drug was also an effective monotherapy agent in adult patients, demonstrating noninferiority to controlled-release carbamazepine, in terms of seizure freedom rates. In paediatric patients, eslicarbazepine acetate provided seizure control when administered as adjunctive therapy, with the benefits appearing to be dependent on age and dose. The antiepileptic efficacy of eslicarbazepine acetate as adjunctive therapy or as monotherapy was maintained during longer-term extension studies, with each extension study period being up to 2 years. Oral eslicarbazepine acetate was generally well tolerated when administered as adjunctive therapy or monotherapy in adult patients and when administered as adjunctive therapy in paediatric patients, with most adverse events being of mild or moderate intensity. In conclusion, with the convenience of once-daily administration, eslicarbazepine acetate is an effective and generally well-tolerated treatment option for adults, adolescents and children aged > 6 years with focal-onset seizures.
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Halford JJ, Edwards JC. Seizure freedom as an outcome in epilepsy treatment clinical trials. Acta Neurol Scand 2020; 142:91-107. [PMID: 32353166 DOI: 10.1111/ane.13257] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/16/2020] [Accepted: 04/26/2020] [Indexed: 12/29/2022]
Abstract
Seizure freedom is recognized as the goal of epilepsy treatment by patients, families, and in treatment guidelines and is associated with notably improved quality of life. However, many studies of epilepsy treatments (including antiseizure medications/antiepileptic drugs, neurostimulation, and dietary therapies) fail to report data on seizure freedom. Even among studies that include this outcome, methods for defining and analyzing seizure freedom vary considerably. Thus, the available data are often difficult to interpret and comparisons between studies are particularly challenging. Although these issues had been identified over a decade ago, there remains a lack of clarity and standardized methods used in analyzing and reporting seizure freedom outcomes in studies of epilepsy treatments. In addition, it remains unclear whether short-term seizure freedom outcomes from pivotal clinical trials are predictive of longer-term seizure freedom outcomes for patients with treatment-refractory epilepsy. Ultimately, the limitations of the available data lead to the potential for misinterpretation and misunderstanding of seizure freedom outcomes associated with the spectrum of available treatments when examining treatment options for patients. Clearly defined outcome analyses of seizure freedom attainment and duration are essential in future clinical studies of treatment for seizures to guide treatment selection and modification for patients.
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Affiliation(s)
- Jonathan J. Halford
- Department of Neurology Medical University of South Carolina Charleston SC USA
| | - Jonathan C. Edwards
- Department of Neurology Medical University of South Carolina Charleston SC USA
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15
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Łuszczki JJ, Kondrat-Wróbel M, Zagaja M, Karwan S, Bojar H, Plewa Z, Florek-Łuszczki M. Sub-additive (antagonistic) interaction of lacosamide with lamotrigine and valproate in the maximal electroshock-induced seizure model in mice: an isobolographic analysis. Pharmacol Rep 2020; 72:1288-1296. [PMID: 32507997 PMCID: PMC7550287 DOI: 10.1007/s43440-020-00117-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 04/20/2020] [Accepted: 05/29/2020] [Indexed: 10/31/2022]
Abstract
BACKGROUND Launching polytherapy with two or three antiseizure drugs (ASDs) in patients with epilepsy is still problematic. The choice of ASDs to combine them together is usually based on clinicians' experience and it requires knowledge about mechanisms of action of the studied ASDs and their drug-drug interactions, whose nature may be favorable, neutral or unfavorable. To characterize three-drug interaction among lacosamide (LCM), lamotrigine (LTG) and valproate (VPA), the type I isobolographic analysis was used. The antiseizure effects of three-drug combination were analyzed in a model of maximal electroshock-induced seizures (MES) in albino Swiss mice. MATERIALS AND METHODS The seizure activity in mice was evoked by alternating current stimulation (25 mA, 500 V, 50 Hz, 0.2 s). Both, the type I isobolographic analysis and the test of parallelism of dose-response effects of the ASDs were used so as to properly classify interaction among three ASDs, administered in a fixed ratio combination of 1:1:1. RESULTS The three-drug mixture of LCM, LTG and VPA at the fixed ratio of 1:1:1 protected the experimental mice from MES-induced seizures; however, the reported interaction was sub-additive (antagonistic; p < 0.01) with isobolography. CONCLUSION The antagonistic pharmacodynamic interaction among LCM, LTG and VPA in the MES test in mice cannot be transferred to clinical settings and this unfavorable combination should not be recommended for patients with epilepsy.
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Affiliation(s)
- Jarogniew J Łuszczki
- Department of Pathophysiology, Medical University, Jaczewskiego 8b, 20-090, Lublin, Poland. .,Isobolographic Analysis Laboratory, Institute of Rural Health, Lublin, Poland.
| | - Maria Kondrat-Wróbel
- Department of Pathophysiology, Medical University, Jaczewskiego 8b, 20-090, Lublin, Poland
| | - Mirosław Zagaja
- Isobolographic Analysis Laboratory, Institute of Rural Health, Lublin, Poland
| | | | - Hubert Bojar
- Department of Toxicology and Food Safety, Institute of Rural Health, Lublin, Poland
| | - Zbigniew Plewa
- Department of General, Oncological and Minimally Invasive Surgery, 1st Military Clinical Hospital, Lublin, Poland
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16
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Pensel MC, Nass RD, Taubøll E, Aurlien D, Surges R. Prevention of sudden unexpected death in epilepsy: current status and future perspectives. Expert Rev Neurother 2020; 20:497-508. [PMID: 32270723 DOI: 10.1080/14737175.2020.1754195] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Introduction: Sudden unexpected death in epilepsy (SUDEP) affects about 1 in 1000 people with epilepsy, and even more in medically refractory epilepsy. As most people are between 20 and 40 years when dying suddenly, SUDEP leads to a considerable loss of potential life years. The most important risk factors are nocturnal and tonic-clonic seizures, underscoring that supervision and effective seizure control are key elements for SUDEP prevention. The question of whether specific antiepileptic drugs are linked to SUDEP is still controversially discussed. Knowledge and education about SUDEP among health-care professionals, patients, and relatives are of outstanding importance for preventive measures to be taken, but still poor and widely neglected.Areas covered: This article reviews epidemiology, pathophysiology, risk factors, assessment of individual SUDEP risk and available measures for SUDEP prevention. Literature search was done using Medline and Pubmed in October 2019.Expert opinion: Significant advances in the understanding of SUDEP were made in the last decade which allow testing of novel strategies to prevent SUDEP. Promising current strategies target neuronal mechanisms of brain stem dysfunction, cardiac susceptibility for fatal arrhythmias, and reliable detection of tonic-clonic seizures using mobile health technologies.Abbreviations: AED, antiepileptic drug; CBZ, carbamazepine; cLQTS, congenital long QT syndrome; EMU, epilepsy monitoring unit; FBTCS, focal to bilateral tonic-clonic seizures; GTCS, generalized tonic-clonic seizures; ICA, ictal central apnea; LTG, lamotrigine; PCCA, postconvulsive central apnea; PGES, postictal generalized EEG suppression; SRI, serotonin reuptake inhibitor; SUDEP, sudden unexpected death in epilepsy; TCS, tonic-clonic seizures.
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Affiliation(s)
| | | | - Erik Taubøll
- Department of Neurology, Oslo University Hospital, Nydalen, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Dag Aurlien
- Neuroscience Research Group and Department of Neurology, Stavanger University Hospital, Stavanger, Norway
| | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
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17
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Hamer HM, Holtkamp M, Kaiser T, Fey S, Rozinat K, Mayer T, Schulze-Bonhage A. Position paper of a German interdisciplinary round table on future designs of trials on adjunctive treatment with antiseizure drugs. Seizure 2020; 78:53-56. [PMID: 32200190 DOI: 10.1016/j.seizure.2020.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 03/05/2020] [Accepted: 03/06/2020] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Current trials on adjunctive treatment with antiseizure drugs often do not reveal results which are relevant for clinical practice. METHOD Therefore, an interdisciplinary group of German experts discussed a new framework for future antiseizure drug (ASD) trials in adults. This group included members of the executive board of the German Society of Epileptology, of the German institutes for health technology assessment (HTA), of patient organizations and of drug manufacturers. Agreement was reached by consensus decision making after intensive discussion of the findings of a narrative review of the current literature. RESULTS The group jointly recommends that ASD trials in adults should be based on and include relevant patient groups, e.g. elderly patients and patients with relevant co-morbidities, should adopt a study duration of at least 12 months, should avoid placebo arms, should include active comparators of clinical relevance, may be designed as open label trials with blinded outcome measurements, should focus on patient relevant outcomes that reflect the impact of benefits and harms of treatments on daily living, such as seizure freedom and seizure severity as well as retention rate, functional outcomes and quality of life as compound measures, and should avoid arbitrary and non-sensitive primary endpoints such as dichotomized changes in seizure frequency. CONCLUSIONS This paper focused on improved head-to-head trials on adjunctive treatment with antiseizure drugs. The group welcomes any further work and discussion to enhance future studies which can be applied to the entire spectrum of potentially meaningful study populations and outcomes.
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Affiliation(s)
- Hajo M Hamer
- Epilepsy Center, Dept. of Neurology, University of Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany.
| | - Martin Holtkamp
- Epilepsy-Center Berlin-Brandenburg, Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Thomas Kaiser
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670 Cologne, Germany
| | - Susanne Fey
- e.b.e. Epilepsie Bundes-Elternverband e.V., Am Eickhof 23, 42111 Wuppertal, Germany
| | - Klaus Rozinat
- Deutsche Epilepsievereinigung e.V., Zillestraße 102, 10585 Berlin, Germany
| | - Thomas Mayer
- Sächsisches Epilepsiezentrum Radeberg, Wachauer Str. 30, D01454 Radeberg, Germany
| | - Andreas Schulze-Bonhage
- Epilepsy Center, University Medical Center Freiburg, Faculty of Medicine, Breisacher Str. 64, D-79106 Freiburg, Germany
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18
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Verrotti A, Lattanzi S, Brigo F, Zaccara G. Pharmacodynamic interactions of antiepileptic drugs: From bench to clinical practice. Epilepsy Behav 2020; 104:106939. [PMID: 32058303 DOI: 10.1016/j.yebeh.2020.106939] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 01/15/2020] [Accepted: 01/17/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Approximately 50% of patients do not achieve seizure control with antiepileptic drug (AED) monotherapy, and polytherapy, with more than one AED, is often required. To date, no evidence-based criteria on how to combine AEDs exist. OBJECTIVE This narrative review aimed to provide critical findings of the available literature about the role of pharmacodynamic AEDs' interactions in patients whose epilepsies were treated with polytherapy. METHODS Electronic databases, Medical Literature Analysis and Retrieval System Online (MEDLINE) and Excerpta Medica dataBASE (EMBASE), were systematically searched to identify relevant studies on pharmacodynamic AEDs' interactions in patients with epilepsy. RESULTS AND CONCLUSION Most data on AED combinations are coming from animal models and preclinical studies. Combining AEDs with different mechanisms of actions seems to have greater effectiveness and lower risk of adverse event development. Conversely, the combination of AEDs may cause pharmacodynamic synergistic effects that may result in not only increased efficacy but also more adverse effects. Despite some AED associations that have been proven to be effective in specific epilepsy/seizure type (e.g., phenobarbital+/phenytoin for tonic seizures and ethosiximide + valproate for absences; lamotrigine + valproate for various epilepsy/seizure types), no clear and definitive evidence exists about AED combinations in humans. Examples of pharmacodynamic interactions that possibly explain the synergistic effects on efficacy or adverse effects include the combination between vigabatrin or pregabalin and sodium channel blockers (supra-additive antiseizure effect) and lacosamide combined with other sodium channel blockers (infra-additive antiseizure effect and neurotoxicity synergistic). The pharmacodynamic lamotrigine-valproate interaction is also supported by synergistic adverse events. Therefore, well-designed double-blind prospective studies recruiting a sufficient number of patients possibly with a crossover design and carefully ascertain the role of pharmacokinetic interactions and variations of AEDs' levels in the blood are needed.
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Affiliation(s)
- Alberto Verrotti
- Department of Pediatrics, University of L'Aquila, L'Aquila, Italy.
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Francesco Brigo
- Hospital Franz Tappeiner, Department of Neurology, Merano, Italy; Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
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Verrotti A, Tambucci R, Di Francesco L, Pavone P, Iapadre G, Altobelli E, Matricardi S, Farello G, Belcastro V. The role of polytherapy in the management of epilepsy: suggestions for rational antiepileptic drug selection. Expert Rev Neurother 2019; 20:167-173. [PMID: 31855066 DOI: 10.1080/14737175.2020.1707668] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Introduction: Antiepileptic polytherapy may be indicated in patients experiencing drug-resistant epilepsy. To date, there are no evidence-based criteria on how to combine different antiepileptic drugs (AEDs) together, in order to obtain the best therapeutic response.Areas covered: This paper reviews the available data about the various associations of AEDs in patients undergoing polytherapy, focusing on the most effective and well-tolerated polytherapies. Moreover, some controversial aspects of this topic are addressed.Expert opinion: Nowadays, there are no guidelines on polytherapy in patients with epilepsy; thus, the management of pharmacoresistant epilepsy is still uncertain, except for valproate/lamotrigine combination, which seems to be the only one recommended. Data regarding mechanism of action, pharmacokinetics, tolerability, and, more importantly, the analysis of the valuable clinical studies of drug combinations can help physicians to choose the best and most effective AED association for each patient.
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Affiliation(s)
- Alberto Verrotti
- Department of Pediatrics, University of L'Aquila, L'Aquila, Italy
| | - Renato Tambucci
- Pediatric Unit, University of L'Aquila, L'Aquila, Italy.,Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Piero Pavone
- Department of Pediatrics, University of Catania, Catania, Italy
| | - Giulia Iapadre
- Department of Pediatrics, University of L'Aquila, L'Aquila, Italy
| | - Emma Altobelli
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Sara Matricardi
- Department of Child Neuropsychiatry, Salesi Hospital Ancona, Italy
| | - Giovanni Farello
- Department of Pediatrics, University of L'Aquila, L'Aquila, Italy
| | - Vincenzo Belcastro
- Child Neuropsychiatry Unit, Department of Mental Health, ASST-LARIANA, COMO
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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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