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Celdran de Castro A, Nascimento FA, Beltran-Corbellini Á, Toledano R, Garcia-Morales I, Gil-Nagel A, Aledo-Serrano Á. Levetiracetam, from broad-spectrum use to precision prescription: A narrative review and expert opinion. Seizure 2023; 107:121-131. [PMID: 37023625 DOI: 10.1016/j.seizure.2023.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/18/2023] [Accepted: 03/22/2023] [Indexed: 04/07/2023] Open
Abstract
Levetiracetam (LEV) is an antiseizure medication (ASM) whose mechanism of action involves the modulation of neurotransmitters release through binding to the synaptic vesicle glycoprotein 2A. It is a broad-spectrum ASM displaying favorable pharmacokinetic and tolerability profiles. Since its introduction in 1999, it has been widely prescribed, becoming the first-line treatment for numerous epilepsy syndromes and clinical scenarios. However, this might have resulted in overuse. Increasing evidence, including the recently published SANAD II trials, suggests that other ASMs are reasonable therapeutic options for generalized and focal epilepsies. Not infrequently, these ASMs show better safety and effectiveness profiles compared to LEV (partially due to the latter's well-known cognitive and behavioral adverse effects, present in up to 20% of patients). Moreover, it has been shown that the underlying etiology of epilepsy is significantly linked to ASMs response in particular scenarios, highlighting the importance of an etiology-based ASM choice. In the case of LEV, it has demonstrated an optimal effectiveness in Alzheimer's disease, Down syndrome, and PCDH19-related epilepsies whereas, in other etiologies such as malformations of cortical development, it may show negligible effects. This narrative review analyzes the current evidence related to the use of LEV for the treatment of seizures. Illustrative clinical scenarios and practical decision-making approaches are also addressed, therefore aiming to define a rational use of this ASM.
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Tsou AY, Kessler SK, Wu M, Abend NS, Massey SL, Treadwell JR. Surgical Treatments for Epilepsies in Children Aged 1-36 Months: A Systematic Review. Neurology 2023; 100:e1-e15. [PMID: 36270898 PMCID: PMC9827129 DOI: 10.1212/wnl.0000000000201012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 06/09/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Early life epilepsies (epilepsies in children 1-36 months old) are common and may be refractory to antiseizure medications. We summarize findings of a systematic review commissioned by the American Epilepsy Society to assess evidence and identify evidence gaps for surgical treatments for epilepsy in children aged 1-36 months without infantile spasms. METHODS EMBASE, MEDLINE, PubMed, and the Cochrane Library were searched for studies published from 1/1/1999 to 8/19/21. We included studies reporting data on children aged 1 month to ≤36 months undergoing surgical interventions or neurostimulation for epilepsy and enrolling ≥10 patients per procedure. We excluded studies of infants with infantile spasms or status epilepticus. For effectiveness outcomes (seizure freedom, seizure frequency), studies were required to report follow-up at ≥ 12 weeks. For harm outcomes, no minimum follow-up was required. Outcomes for all epilepsy types, regardless of etiology, were reported together. RESULTS Eighteen studies (in 19 articles) met the inclusion criteria. Sixteen prestudies/poststudies reported on efficacy, and 12 studies addressed harms. Surgeries were performed from 1979 to 2020. Seizure freedom for infants undergoing hemispherectomy/hemispherotomy ranged from 7% to 76% at 1 year after surgery. For nonhemispheric surgeries, seizure freedom ranged from 40% to 70%. For efficacy, we concluded low strength of evidence (SOE) suggests some infants achieve seizure freedom after epilepsy surgery. Over half of infants undergoing hemispherectomy/hemispherotomy achieved a favorable outcome (Engel I or II, International League Against Epilepsy I to IV, or >50% seizure reduction) at follow-up of >1 year, although studies had key limitations. Surgical mortality was rare for functional hemispherectomy/hemispherotomy and nonhemispheric resections. Low SOE suggests postoperative hydrocephalus is uncommon for infants undergoing nonhemispheric procedures for epilepsy. DISCUSSION Although existing evidence remains sparse and low quality, some infants achieve seizure freedom after surgery and ≥50% achieve favorable outcomes. Future prospective studies in this age group are needed. In addition to seizure outcomes, studies should evaluate other important outcomes (developmental outcomes, quality of life [QOL], sleep, functional performance, and caregiver QOL). TRIAL REGISTRATION INFORMATION This systematic review was registered in PROSPERO (CRD42021220352) on March 5, 2021.
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Affiliation(s)
- Amy Y Tsou
- From the ECRI Evidence Based Practice Center (A.Y.T., M.W., J.R.T.), Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Biostatistics (N.S.A.), Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine.
| | - Sudha Kilaru Kessler
- From the ECRI Evidence Based Practice Center (A.Y.T., M.W., J.R.T.), Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Biostatistics (N.S.A.), Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
| | - Mingche Wu
- From the ECRI Evidence Based Practice Center (A.Y.T., M.W., J.R.T.), Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Biostatistics (N.S.A.), Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
| | - Nicholas S Abend
- From the ECRI Evidence Based Practice Center (A.Y.T., M.W., J.R.T.), Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Biostatistics (N.S.A.), Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
| | - Shavonne L Massey
- From the ECRI Evidence Based Practice Center (A.Y.T., M.W., J.R.T.), Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Biostatistics (N.S.A.), Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
| | - Jonathan R Treadwell
- From the ECRI Evidence Based Practice Center (A.Y.T., M.W., J.R.T.), Plymouth Meeting, PA; Division of Neurology (A.Y.T.), Michael J Crescenz Veterans Affairs Medical Center, Philadelphia; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Department of Biostatistics (N.S.A.), Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
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Treadwell JR, Kessler SK, Wu M, Abend NS, Massey SL, Tsou AY. Pharmacologic and Dietary Treatments for Epilepsies in Children Aged 1-36 Months: A Systematic Review. Neurology 2023; 100:e16-e27. [PMID: 36270899 PMCID: PMC9827128 DOI: 10.1212/wnl.0000000000201026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 06/13/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Early life epilepsies are common and often debilitating, but no evidence-based management guidelines exist outside of those for infantile spasms. We conducted a systematic review of the effectiveness and harms of pharmacologic and dietary treatments for epilepsy in children aged 1-36 months without infantile spasms. METHODS We searched EMBASE, MEDLINE, PubMed, and the Cochrane Library for studies published from January 1, 1999, to August 19, 2021. Using prespecified criteria, we identified studies reporting data on children aged 1-36 months receiving pharmacologic or dietary treatments for epilepsy. We did not require that studies report etiology-specific data. We excluded studies of neonates, infantile spasms, and status epilepticus. We included studies administering 1 of 29 pharmacologic treatments and/or 1 of 5 dietary treatments reporting effectiveness outcomes at ≥ 12 weeks. We reviewed the full text to find any subgroup analyses of children aged 1-36 months. RESULTS Twenty-three studies met inclusion criteria (6 randomized studies, 2 nonrandomized comparative studies, and 15 prestudies/poststudies). All conclusions were rated low strength of evidence. Levetiracetam leads to seizure freedom in some infants (32% and 66% in studies reporting seizure freedom), but data on 6 other medications were insufficient to permit conclusions about effectiveness (topiramate, lamotrigine, phenytoin, vigabatrin, rufinamide, and stiripentol). Three medications (levetiracetam, topiramate, and lamotrigine) were rarely discontinued because of adverse effects, and severe events were rare. For diets, the ketogenic diet leads to seizure freedom in some infants (rates 12%-37%), and both the ketogenic diet and modified Atkins diet reduce average seizure frequency, but reductions are greater with the ketogenic diet (1 RCT reported a 71% frequency reduction at 6 months for ketogenic diet vs only a 28% reduction for the modified Atkins diet). Dietary harms were not well-reported. DISCUSSION Little high-quality evidence exists on pharmacologic and dietary treatments for early life epilepsies. Future research should isolate how treatments contribute to outcomes, conduct etiology-specific analyses, and report patient-centered outcomes such as hospitalization, neurodevelopment, functional performance, sleep quality, and patient and caregiver quality of life. TRIAL REGISTRATION INFORMATION This systematic review was registered in PROSPERO (CRD42021220352) on March 5, 2021.
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Affiliation(s)
- Jonathan R Treadwell
- From the ECRI-Penn Medicine Evidence-based Practice Center (J.R.T., M.W., A.Y.T.), ECRI, Plymouth Meeting, PA; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Biostatistics, Epidemiology and Informatics (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Division of Neurology (A.Y.T.), Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA.
| | - Sudha Kilaru Kessler
- From the ECRI-Penn Medicine Evidence-based Practice Center (J.R.T., M.W., A.Y.T.), ECRI, Plymouth Meeting, PA; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Biostatistics, Epidemiology and Informatics (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Division of Neurology (A.Y.T.), Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA
| | - Mingche Wu
- From the ECRI-Penn Medicine Evidence-based Practice Center (J.R.T., M.W., A.Y.T.), ECRI, Plymouth Meeting, PA; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Biostatistics, Epidemiology and Informatics (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Division of Neurology (A.Y.T.), Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA
| | - Nicholas S Abend
- From the ECRI-Penn Medicine Evidence-based Practice Center (J.R.T., M.W., A.Y.T.), ECRI, Plymouth Meeting, PA; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Biostatistics, Epidemiology and Informatics (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Division of Neurology (A.Y.T.), Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA
| | - Shavonne L Massey
- From the ECRI-Penn Medicine Evidence-based Practice Center (J.R.T., M.W., A.Y.T.), ECRI, Plymouth Meeting, PA; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Biostatistics, Epidemiology and Informatics (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Division of Neurology (A.Y.T.), Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA
| | - Amy Y Tsou
- From the ECRI-Penn Medicine Evidence-based Practice Center (J.R.T., M.W., A.Y.T.), ECRI, Plymouth Meeting, PA; Department of Pediatrics (Division of Neurology) (S.K.K., N.S.A., S.L.M.), Children's Hospital of Philadelphia; Departments of Neurology and Pediatrics (S.K.K., N.S.A., S.L.M.), University of Pennsylvania Perelman School of Medicine; Department of Anesthesia & Critical Care (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Biostatistics, Epidemiology and Informatics (N.S.A.), University of Pennsylvania Perelman School of Medicine; and Division of Neurology (A.Y.T.), Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA
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Glass HC, Shellhaas RA. Early discontinuation of antiseizure medication in neonatal seizures - Proceed with caution. J Neonatal Perinatal Med 2022; 15:495-498. [PMID: 34864694 DOI: 10.3233/npm-210882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- H C Glass
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA, USA
- Department of Pediatrics; UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics; University of California San Francisco, San Francisco, CA, USA
| | - R A Shellhaas
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
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Surtees TL, Kumar I, Garton HJL, Rivas-Rodriguez F, Parmar H, McCaffery H, Riebe-Rodgers J, Shellhaas RA. Levetiracetam Prophylaxis for Children Admitted With Traumatic Brain Injury. Pediatr Neurol 2022; 126:114-119. [PMID: 34839268 DOI: 10.1016/j.pediatrneurol.2021.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 10/02/2021] [Accepted: 10/11/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Prophylactic antiseizure medications (ASMs) for pediatric traumatic brain injury (TBI) are understudied. We evaluated clinical and radiographic features that inform prescription of ASMs for pediatric TBI. We hypothesized that despite a lack of evidence, levetiracetam is the preferred prophylactic ASM but that prophylaxis is inconsistently prescribed. METHODS This retrospective study assessed children admitted with TBI from January 1, 2017, to December 31, 2019. TBI severity was defined using Glasgow Coma Scale (GCS) scores. Two independent neuroradiologists reviewed initial head computed tomography and brain magnetic resonance imaging. Fisher exact tests and descriptive and regression analyses were conducted. RESULTS Among 167 children with TBI, 44 (26%) received ASM prophylaxis. All 44 (100%) received levetiracetam. Prophylaxis was more commonly prescribed for younger children, those with neurosurgical intervention, and abnormal neuroimaging (particularly intraparenchymal hematoma) (odds ratio = 10.3, confidence interval 1.8 to 58.9), or GCS ≤12. Six children (13.6%), all on ASM, developed early posttraumatic seizures (EPTSs). Of children with GCS ≤12, four of 17 (23.5%) on levetiracetam prophylaxis developed EPTSs, higher than the reported rate for phenytoin. CONCLUSIONS Although some studies suggest it may be inferior to phenytoin, levetiracetam was exclusively used for EPTS prophylaxis. Intraparenchymal hematoma >1 cm was the single neuroimaging feature associated with ASM prophylaxis regardless of the GCS score. Yet these trends are not equivalent to optimal evidence-based management. We still observed important variability in neuroimaging characteristics and TBI severity for children on prophylaxis. Thus, further study of ASM prophylaxis and prevention of pediatric EPTSs is warranted.
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Affiliation(s)
- Taryn-Leigh Surtees
- Department of Neurology, Washington University in St. Louis School of Medicine, St. Louis, Missouri.
| | - Ishani Kumar
- Departments of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | | | | | - Hemant Parmar
- Radiology, University of Michigan, Ann Arbor, Michigan
| | - Harlan McCaffery
- Departments of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | | | - Renée A Shellhaas
- Departments of Pediatrics, University of Michigan, Ann Arbor, Michigan
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Hussain SA, Heesch J, Weng J, Rajaraman RR, Numis AL, Sankar R. Potential induction of epileptic spasms by nonselective voltage-gated sodium channel blockade: Interaction with etiology. Epilepsy Behav 2021; 115:107624. [PMID: 33341392 DOI: 10.1016/j.yebeh.2020.107624] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/28/2020] [Accepted: 11/05/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Epileptic spasms are often preceded by focal (or multifocal) seizures. Based on a series of case reports suggesting that carbamazepine and oxcarbazepine may induce epileptic spasms, we set out to rigorously evaluate the potential association between exposure to voltage-gated sodium channel blockade and latency to epileptic spasms. METHODS We identified 50 cases (children with focal seizures and evolution to epileptic spasms) and 50 controls (children with focal seizures without evolution to epileptic spasms). For each patient, we reviewed all sequential neurology encounters between onset of epilepsy and emergence of epileptic spasms. For each encounter we recorded seizure-frequency and all anti-seizure therapy exposures. Using multivariable Cox proportional hazards regression, we evaluated the association between voltage-gated sodium channel exposure (carbamazepine, oxcarbazepine, lacosamide, or phenytoin) and latency to epileptic spasms onset, with adjustment for etiology and seizure-frequency. RESULTS Latency to epileptic spasms onset was independently associated with exposure to sodium channel blockade (hazard ratio = 2.4; 95% CI 1.1-5.2; P = 0.03) and high-risk etiology (hazard ratio = 2.8; 95% CI 1.5-5.1; P = 0.001). With assessment for interaction between sodium channel blockade and etiology, we identified an estimated 7-fold increased risk of epileptic spasms with the combination of sodium channel blockade and high-risk etiology (hazard ratio = 7.0, 95% CI 2.5-19.8; P < 0.001). CONCLUSION This study suggests that voltage-gated sodium channel blockade may induce epileptic spasms among children at risk on the basis of etiology. Further study is warranted to replicate these findings, ascertain possible drug- and dose-specific risks, and identify potential mechanisms of harm.
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Affiliation(s)
- Shaun A Hussain
- Division of Pediatric Neurology, David Geffen School of Medicine and UCLA Mattel Children's Hospital, Los Angeles, CA, United States.
| | - Jaeden Heesch
- Division of Pediatric Neurology, David Geffen School of Medicine and UCLA Mattel Children's Hospital, Los Angeles, CA, United States
| | - Julius Weng
- Division of Pediatric Neurology, David Geffen School of Medicine and UCLA Mattel Children's Hospital, Los Angeles, CA, United States
| | - Rajsekar R Rajaraman
- Division of Pediatric Neurology, David Geffen School of Medicine and UCLA Mattel Children's Hospital, Los Angeles, CA, United States
| | - Adam L Numis
- Departments of Neurology and Pediatrics, UCSF Benioff Children's Hospital, San Francisco, CA, United States
| | - Raman Sankar
- Division of Pediatric Neurology, David Geffen School of Medicine and UCLA Mattel Children's Hospital, Los Angeles, CA, United States
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Nickels K, Kossoff EH, Eschbach K, Joshi C. Epilepsy with myoclonic-atonic seizures (Doose syndrome): Clarification of diagnosis and treatment options through a large retrospective multicenter cohort. Epilepsia 2020; 62:120-127. [PMID: 33190223 DOI: 10.1111/epi.16752] [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: 08/26/2020] [Revised: 10/14/2020] [Accepted: 10/14/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Epilepsy with myoclonic-atonic seizures (EMAS) is a rare childhood onset epileptic encephalopathy. There is no clear consensus for recommended treatments, and pharmacoresistance is common. To better assess the clinical phenotype, most effective treatment, and determinants of cognitive and seizure outcomes, three major pediatric epilepsy centers combined data, creating the largest cohort of patients with EMAS ever studied to date. METHODS Authors performed a retrospective chart review of patients with EMAS who received care at the authors' institutions. RESULTS A total of 166 children were identified. Global developmental delay (>1 domain) was present in 2% of children at onset and 49% during the course of the disease. Afebrile seizures occurred after the age of 2 years in 88%, generalized tonic-clonic seizures in 60%, and drop attack or myoclonic seizures in 30%. At onset, electroencephalography (EEG) found 28% normal, background slowing in 20%, and epileptiform discharges or seizures in 69%. Subsequent EEG found slowing in 62% and discharges or seizures in 90%. Response (>50% seizure reduction) to the first three antiseizure drugs (ASDs) was 26% (levetiracetam, 17%; valproic acid, 31%; other ASDs combined, 26%). Diet therapy was used as a second or third therapy in 19% and ultimately used in 57%; response was 79%, significantly greater than the first three ASDs (P = .005, χ2 ). Seizure freedom occurred in 57% and was less likely in the case of persistent global developmental delays (P < .001), seizure recorded on subsequent EEGs (P = .027), and failure to respond to diet therapy (P = .005). Development was normal in 47%, and 12% had delays in one domain, which was less likely in the case of global developmental delay after epilepsy onset (P < .001) and failure to achieve seizure freedom (P < .001). SIGNIFICANCE This large cohort of children with EMAS clarifies areas of variability in practice. Diet therapy is by far the most effective treatment; failure to respond was associated with failure to attain seizure freedom. This therapy should be used early in the treatment in EMAS. This study also identified a bidirectional link between cognitive and seizure outcomes.
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Affiliation(s)
| | - Eric H Kossoff
- Departments of Neurology and Pediatrics, Johns Hopkins University, Baltimore, MD, USA
| | - Krista Eschbach
- Children's Hospital of Colorado, University of Colorado Denver Anschutz School of Medicine, Aurora, CO, USA
| | - Charuta Joshi
- Children's Hospital of Colorado, University of Colorado Denver Anschutz School of Medicine, Aurora, CO, USA
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Hnaini M, Darwich M, Koleilat N, Jaafar F, Hanneyan S, Rahal S, Mikati IE, Shbarou RM, Nabout R, Maalouf FI, Obeid M. High-Dose Levetiracetam for Neonatal Seizures: A Retrospective Review. Seizure 2020; 82:7-11. [PMID: 32950862 DOI: 10.1016/j.seizure.2020.08.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 08/20/2020] [Accepted: 08/27/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Neonatal seizures are frequently encountered in the neonatal intensive care unit and may be associated with serious long-term neurological sequelae. Response to treatment continues to be modest, and treatment guidelines remain unclear. The use of levetiracetam has been on the rise in the past several years due to its favorable safety profile in the face of limited data on its efficacy and optimal dosing regimens. Unlike the older age groups, the benefit of escalating to high-dose levetiracetam of 80-100 mg/kg/day in neonates not responding to the standard used dosing regimen (40-60 mg/kg/day) is not studied. We sought to investigate the safety and efficacy of levetiracetam escalation to high dose regimens for neonatal seizures. METHODS A retrospective chart review over a 7-year period was conducted at the American University of Beirut to identify neonates with electrographically proven seizures treated with levetiracetam. Data was collected on electroclinical seizure characteristics, underlying etiology, seizure control, other anti-seizure medications, and adverse effects. RESULTS Electronic chart review revealed a total of 15 neonates with electrographically confirmed seizures treated with levetiracetam, with escalation to high doses in seven. As a first line drug, levetiracetam monotherapy terminated seizures in six out 10 neonates, two of whom had complete seizure cessation only after escalation to high doses of 80 or 100 mg/kg/day. When used in combination with other anti-seizure medications, four out of five neonates achieved complete seizure cessation upon escalation to high doses of levetiracetam. No adverse effects were noted. CONCLUSIONS In neonates not responding to the standard used levetiracetam doses, incremental increases to 80-100 mg/kg/day may be considered. Prospective studies are needed to confirm the promising role of such high dosing regimens, and to better elucidate the role of levetiracetam in neonatal seizures.
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Affiliation(s)
- Mona Hnaini
- Division of Child Neurology, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mouhamad Darwich
- Division of Child Neurology, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nadia Koleilat
- Division of Child Neurology, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Fatima Jaafar
- Division of Child Neurology, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Sarin Hanneyan
- Division of Child Neurology, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Simon Rahal
- Division of Child Neurology, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | | | - Rolla M Shbarou
- Division of Child Neurology, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rita Nabout
- Faculty of Science, Lebanese University, Beirut, Lebanon
| | - Faouzi I Maalouf
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
| | - Makram Obeid
- Division of Child Neurology, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon; Department of Anatomy, Cell Biology and Physiological Sciences, American University of Beirut, Beirut, Lebanon.
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Pavlakis SG. Reply to Grinspan et al. Pediatr Neurol 2019; 100:105-106. [PMID: 31481329 DOI: 10.1016/j.pediatrneurol.2019.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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10
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Nolan D, Lester SG, Rau SM, Shellhaas RA. Clinical Use and Efficacy of Levetiracetam for Absence Epilepsies. J Child Neurol 2019; 34:94-98. [PMID: 30458657 DOI: 10.1177/0883073818811511] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Levetiracetam is prescribed for a broad spectrum of seizure types but does not have a specific indication for absence epilepsy. We hypothesized that levetiracetam is commonly prescribed for children with absence epilepsies and evaluated the efficacy of this medication for absence epilepsy treatment in clinical practice. We also hypothesized that electroencephalographic (EEG) findings could help predict levetiracetam efficacy. METHODS We reviewed the charts of all patients treated for new-onset absence epilepsies at our pediatric neurology clinic between January 2011 and January 2016. Among 158 children diagnosed with absence epilepsies, 72 were treated with levetiracetam. RESULTS Levetiracetam was discontinued in 74% (n = 53/72) because of incomplete seizure control (59%, n = 35/72) and/or intolerable side effects (41%, n = 24/72) after a median 8.5 months (interquartile range 2, 17 months). Among patients for whom levetiracetam was effective, 44% (n = 8/18) had polyspikes on their initial EEG, versus 27% (n = 14/52) of patients for whom levetiracetam was discontinued ( P = .17). The maximal prescribed dose was lower for children in whom levetiracetam was effective (29 ± 13 mg/kg/d) than those for whom levetiracetam failed (42 ± 20 mg/kg/d; P = .005). CONCLUSION In routine clinical practice, levetiracetam is often chosen for patients with absence seizures. However, only about one-quarter of children with absence epilepsy in this study became seizure free with levetiracetam. When effective, levetiracetam can control absence epilepsy at a relatively low dose. Lack of seizure control requiring continued dose escalation should prompt early consideration of a therapeutic medication transition.
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Affiliation(s)
- Danielle Nolan
- 1 Division of Epilepsy, Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Shannon G Lester
- 2 Division of Pediatric Neurology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Stephanie M Rau
- 2 Division of Pediatric Neurology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Reneé A Shellhaas
- 2 Division of Pediatric Neurology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
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Cohen NT, Chamberlain JM, Gaillard WD. Timing and selection of first antiseizure medication in patients with pediatric status epilepticus. Epilepsy Res 2019; 149:21-25. [DOI: 10.1016/j.eplepsyres.2018.10.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 10/17/2018] [Accepted: 10/27/2018] [Indexed: 10/28/2022]
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12
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Nickels K. Medications for Early Life Epilepsy: Evidence Versus Experience? Epilepsy Curr 2019; 19:33-35. [PMID: 30838916 PMCID: PMC6610368 DOI: 10.1177/1535759718822130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Comparative Effectiveness of Levetiracetam vs Phenobarbital for
Infantile Epilepsy Grinspan ZM, Shellhaas RA, Coryell J, Sullivan JE, Wirrell EC, Mytinger
JR, Gaillard WD, Kossoff EH, Valencia I, Knupp KG, Wusthoff C, Keator C,
Ryan N, Loddenkemper T, Chu CJ, Novotny EJ Jr, Millichap J, Berg AT.
JAMA Pediatr. 2018 Apr 1;172(4):352-360. doi:
10.1001/jamapediatrics.2017.5211. Importance: More than half of infants with new-onset epilepsy have
electroencephalographic and clinical features that do not conform to
known electroclinical syndromes (ie, nonsyndromic epilepsy).
Levetiracetam and phenobarbital are the most commonly prescribed
medications for epilepsy in infants, but their comparative effectiveness
is unknown. Objective: To compare the effectiveness of levetiracetam
versus phenobarbital for nonsyndromic infantile epilepsy. Design,
Setting, and Participants: The Early Life Epilepsy Study—a prospective,
multicenter, observational cohort study conducted from March 1, 2012, to
April 30, 2015, in 17 US medical centers—enrolled infants with
nonsyndromic epilepsy and a first afebrile seizure between 1 month and 1
year of age. Exposures: Use of levetiracetam or phenobarbital as initial
monotherapy within 1 year of the first seizure. Main Outcomes and
Measures: The binary outcome was freedom from monotherapy failure at 6
months, defined as no second prescribed antiepileptic medication and
freedom from seizures beginning within 3 months of initiation of
treatment. Outcomes were adjusted for demographics, epilepsy
characteristics, and neurologic history, as well as for observable
selection bias using propensity score weighting and for within-center
correlation using generalized estimating equations. Results: Of the 155
infants in the study (81 girls and 74 boys; median age, 4.7 months
[interquartile range, 3.0-7.1 months]), those treated with levetiracetam
(n = 117) were older at the time of the first seizure than those treated
with phenobarbital (n = 38; median age, 5.2 months [interquartile range,
3.5-8.2 months] vs 3.0 months [interquartile range, 2.0-4.4 months];
P < .001). There were no other significant
bivariate differences. Infants treated with levetiracetam were free from
monotherapy failure more often than those treated with phenobarbital (47
[40.2%] vs 6 [15.8%]; P = .01). The superiority of
levetiracetam over phenobarbital persisted after adjusting for
covariates, observable selection bias, and within-center correlation
(odds ratio, 4.2; 95% confidence interval [CI], 1.1-16; number needed to
treat, 3.5 [95% CI, 1.7-60]). Conclusions and Relevance: Levetiracetam
may have superior effectiveness compared to phenobarbital for initial
monotherapy of nonsyndromic epilepsy in infants. If 100 infants who
received phenobarbital were instead treated with levetiracetam, 44 would
be free from monotherapy failure instead of 16 by the estimates in this
study. Randomized clinical trials are necessary to confirm these
findings.
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13
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Berg AT, Goldman S. Getting serious about the early-life epilepsies. Neurology 2018; 90:842-848. [DOI: 10.1212/wnl.0000000000005423] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 02/15/2018] [Indexed: 12/15/2022] Open
Abstract
Early-life epilepsies represent a group of many individually rare and often complex developmental brain disorders associated with lifelong devastating consequences and high risk for early mortality. The quantity and quality of evidence needed to guide the evaluation and treatment to optimize outcomes of affected children is minimal; most children are treated within an evidence-free practice zone based solely on anecdote and lore. The remarkable advances in diagnostics and therapeutics are implemented haphazardly with no systematic effort to understand their effects and value. This stands in stark contrast to the evidence-rich practice of the Children's Oncology Group, where standard of care treatments are identified through rigorous, multicenter research studies, and the vast majority of patients are treated on protocols developed from that research. As a consequence, overall mortality for childhood cancers has declined from ∼90% in the 1950s to ∼20% today. The situations of these 2 rare disease specialties are contrasted, and some suggestions for moving early-life epilepsy onto a fast track for success are offered. Chief amongst these is that early-life epilepsy should be treated with the same urgency as pediatric cancer. The best diagnostics and evidence-based treatments should be used in a systematic fashion right from the start, not after the child and family have been subjected to the ravages of the disorder for months or years. This will require unity and cooperation among physicians, researchers, and institutions across state and national borders.
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14
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Grinspan ZM, Shellhaas RA, Coryell J, Sullivan JE, Wirrell EC, Mytinger JR, Gaillard WD, Kossoff EH, Valencia I, Knupp KG, Wusthoff C, Keator C, Ryan N, Loddenkemper T, Chu CJ, Novotny EJ, Millichap J, Berg AT. Comparative Effectiveness of Levetiracetam vs Phenobarbital for Infantile Epilepsy. JAMA Pediatr 2018; 172:352-360. [PMID: 29435578 PMCID: PMC5875334 DOI: 10.1001/jamapediatrics.2017.5211] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE More than half of infants with new-onset epilepsy have electroencephalographic and clinical features that do not conform to known electroclinical syndromes (ie, nonsyndromic epilepsy). Levetiracetam and phenobarbital are the most commonly prescribed medications for epilepsy in infants, but their comparative effectiveness is unknown. OBJECTIVE To compare the effectiveness of levetiracetam vs phenobarbital for nonsyndromic infantile epilepsy. DESIGN, SETTING, AND PARTICIPANTS The Early Life Epilepsy Study-a prospective, multicenter, observational cohort study conducted from March 1, 2012, to April 30, 2015, in 17 US medical centers-enrolled infants with nonsyndromic epilepsy and a first afebrile seizure between 1 month and 1 year of age. EXPOSURES Use of levetiracetam or phenobarbital as initial monotherapy within 1 year of the first seizure. MAIN OUTCOMES AND MEASURES The binary outcome was freedom from monotherapy failure at 6 months, defined as no second prescribed antiepileptic medication and freedom from seizures beginning within 3 months of initiation of treatment. Outcomes were adjusted for demographics, epilepsy characteristics, and neurologic history, as well as for observable selection bias using propensity score weighting and for within-center correlation using generalized estimating equations. RESULTS Of the 155 infants in the study (81 girls and 74 boys; median age, 4.7 months [interquartile range, 3.0-7.1 months]), those treated with levetiracetam (n = 117) were older at the time of the first seizure than those treated with phenobarbital (n = 38) (median age, 5.2 months [interquartile range, 3.5-8.2 months] vs 3.0 months [interquartile range, 2.0-4.4 months]; P < .001). There were no other significant bivariate differences. Infants treated with levetiracetam were free from monotherapy failure more often than those treated with phenobarbital (47 [40.2%] vs 6 [15.8%]; P = .01). The superiority of levetiracetam over phenobarbital persisted after adjusting for covariates, observable selection bias, and within-center correlation (odds ratio, 4.2; 95% CI, 1.1-16; number needed to treat, 3.5 [95% CI, 1.7-60]). CONCLUSIONS AND RELEVANCE Levetiracetam may have superior effectiveness compared with phenobarbital for initial monotherapy of nonsyndromic epilepsy in infants. If 100 infants who received phenobarbital were instead treated with levetiracetam, 44 would be free from monotherapy failure instead of 16 by the estimates in this study. Randomized clinical trials are necessary to confirm these findings.
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Affiliation(s)
- Zachary M. Grinspan
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, New York,Department of Pediatrics, Weill Cornell Medicine, New York, New York,New York–Presbyterian Komansky Children’s Hospital, New York, New York
| | - Renée A. Shellhaas
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor
| | - Jason Coryell
- Department of Pediatrics, Oregon Health & Sciences University, Portland,Department of Neurology, Oregon Health & Sciences University, Portland
| | | | | | - John R. Mytinger
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus
| | - William D. Gaillard
- Department of Neurology, Children’s National Health System, George Washington University School of Medicine, Washington, DC
| | - Eric H. Kossoff
- Department of Neurology, Johns Hopkins Hospital, Baltimore, Maryland,Department of Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland
| | - Ignacio Valencia
- Section of Neurology, St. Christopher’s Hospital for Children, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Kelly G. Knupp
- Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora,Department of Neurology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora
| | - Courtney Wusthoff
- Division of Child Neurology, Stanford University, Palo Alto, California
| | - Cynthia Keator
- Comprehensive Epilepsy Program, Jane and John Justin Neuroscience Center, Cook Children’s Medical Center, Fort Worth, Texas
| | - Nicole Ryan
- Division of Neurology, The Children’s Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Edward J. Novotny
- Division of Pediatric Neurology, Seattle Children’s Hospital, Seattle, Washington,Department of Neurology, University of Washington, Seattle,Department of Pediatrics, University of Washington, Seattle,Center for Integrative Brain Research, University of Washington, Seattle
| | - John Millichap
- Epilepsy Center, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois,Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Anne T. Berg
- Epilepsy Center, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois,Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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15
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Levetiracetam monotherapy for the treatment of infants with epilepsy. Seizure 2018; 56:73-77. [DOI: 10.1016/j.seizure.2018.02.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 02/07/2018] [Accepted: 02/09/2018] [Indexed: 01/31/2023] Open
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