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Hanaya R, Kubota Y, Mizobuchi M, Iida K, Ono T, Motooka H, Nakano N, Fujimoto A, Iwasaki M, Fukuda M, Kondo A, Uruno K, Yamamuro S, Yamaguchi K, Onishi K, Ngo LY, Inoue Y. Intravenous perampanel as an alternative to the oral formulations in Japanese patients with epilepsy. Epilepsia Open 2023; 8:1369-1382. [PMID: 37547978 PMCID: PMC10690696 DOI: 10.1002/epi4.12804] [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: 03/01/2023] [Accepted: 08/02/2023] [Indexed: 08/08/2023] Open
Abstract
OBJECTIVE Perampanel is an oral anti-seizure medication, which is approved in Japan for focal-onset seizures, with/without focal to bilateral tonic-clonic seizures, as monotherapy/adjunctive therapy in patients aged 4 years and older. Treatment for generalized tonic-clonic seizures as adjunctive therapy in patients aged 12 years and older is approved as well. We evaluated the feasibility of intravenous (IV) administration of perampanel as an alternative to oral administration. METHODS Study 240 (NCT03754582) was an uncontrolled, open-label study of IV perampanel, conducted in 21 Japanese patients with epilepsy who received a stable dose of 8-12 mg/day of oral perampanel. Patients received 30-minute IV infusions at equivalent daily doses of oral perampanel for 4 days, then were switched back to oral perampanel. Safety, tolerability, plasma concentration, and maintenance of efficacy throughout the transition between IV and oral dosing of perampanel were assessed. As supportive data, a subgroup analysis was also conducted using data from healthy Japanese subjects (n = 18) who were enrolled in Study 050 (NCT03376997) investigating the pharmacokinetics and safety of IV perampanel in healthy subjects who received an IV infusion (30-, 60-, or 90-minute) of perampanel 12 mg and a single oral administration of perampanel 12-mg tablet. RESULTS In Study 240, the transition between 30-minute IV and oral perampanel dosing was associated with a ≤1.4-fold increase in the mean change in maximum observed concentration of perampanel. Seizure outcomes demonstrated no considerable changes in efficacy before, during, or after 30-minute IV dosing of perampanel. The safety profiles were similar between IV and oral formulations. In Study 050, the pharmacokinetics of 30- or 60-minute IV infusion of perampanel further support the interchangeability between oral and IV formulations in the Japanese subjects. SIGNIFICANCE These results support that 30-minute IV perampanel may be a potential short-term alternative to oral formulations for patients with epilepsy.
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Affiliation(s)
- Ryosuke Hanaya
- Department of NeurosurgeryKagoshima University, Graduate School of Medical and Dental SciencesKagoshimaJapan
| | - Yuichi Kubota
- Epilepsy Center, TMG Asaka Medical CenterAsakaJapan
- Present address:
Department of NeurosurgeryTokyo Women's Medical University, Adachi Medical CenterAdachiTokyoJapan
| | - Masahiro Mizobuchi
- Department of NeurologyNakamura Memorial HospitalSapporoJapan
- Present address:
Department of NeurologyMinami‐ichijo Neurology ClinicSapporoHokkaidoJapan
| | - Koji Iida
- Epilepsy Center, Hiroshima University HospitalHiroshimaJapan
| | - Tomonori Ono
- Epilepsy Center, National Hospital Organization Nagasaki Medical CenterOmuraJapan
| | | | - Naoki Nakano
- Department of NeurosurgeryKindai UniversityOsakasayamaJapan
| | - Ayataka Fujimoto
- Comprehensive Epilepsy Center, Seirei Hamamatsu General HospitalHamamatsuJapan
| | - Masaki Iwasaki
- Department of NeurosurgeryNational Center Hospital, National Center of Neurology and PsychiatryKodairaJapan
| | - Masafumi Fukuda
- Department of NeurosurgeryNational Hospital Organization Nishiniigata Chuo HospitalNiigataJapan
| | - Akihiko Kondo
- Department of NeurosurgeryNational Hospital Organization, Shizuoka Institute of Epilepsy and Neurological DisordersShizuokaJapan
| | - Katsuhisa Uruno
- Department of NeurologyNational Hospital Organization Yamagata HospitalYamagataJapan
| | | | | | | | | | - Yushi Inoue
- National Hospital Organization, Shizuoka Institute of Epilepsy and Neurological DisordersShizuokaJapan
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Pöytäkangas T, Saarinen JT, Basnyat P, Rainesalo S, Peltola J. Indications for the use of intravenous second-line antiseizure medications in an emergency room setting. Epilepsy Res 2023; 196:107218. [PMID: 37647825 DOI: 10.1016/j.eplepsyres.2023.107218] [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: 03/21/2023] [Revised: 08/11/2023] [Accepted: 08/21/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Second-line iv antiseizure medications (ASMs) are used to treat status epilepticus (SE), but in the emergency room setting, there might be other intended and unintended indications for administration. We wanted to explore these different indications and assess the actual usage of first- and second-line ASMs for SE with reference to other uses, such as for SE mimics. METHODS In this retrospective study, we searched the electronic patient registry with the following terms: "epilepsy", "SE", and "seizure", during 2015. Patients at least 16 years old and treated with iv second-line ASMs were further analysed. We reassessed the indications for the use of iv ASMs based on clinical features and examinations performed. RESULTS A total of 166 episodes from 136 patients with a median age of 66 years were evaluated, constituting the following indication categories: ongoing SE (48.2%), recurrent seizures (19.3%), postictal (12.1%), seizure mimics (10.2%) and prophylactic use of ASMs (10.2%). Ongoing SE included the following subgroups: convulsive SE, focal aware SE, nonconvulsive SE (NCSE) and NCSE with coma. The seizure mimics group had a preexisting epilepsy diagnosis more often than the ongoing SE group (73% vs. 44%, p = 0.039). Ischaemic stroke was the most frequent seizure mimic. EEG was performed during hospital admission in 78% of patients with ongoing SE, 50% of patients with recurrent seizures, 75% of patients with postictal state, 53% of seizure mimic episodes and 12% of the prophylactic group. In NCSE and comatose NCSE, the diagnosis was made, and treatment was initiated only after an EEG in 52% and 30% of cases, respectively. The use of newer second-line ASMs (levetiracetam and lacosamide) was frequent in our study population. Immediate side effects of ASMs were infrequent. CONCLUSIONS Even though most of the use of ASMs was justified and administered for SE, it is a diagnostic challenge where a prior diagnosis of epilepsy can be a misleading factor, and EEG is an essential tool when clinical features are often overlapping with other acute seizure disorders. Side effects of the newer second-line ASMs after a single dose are infrequent.
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Affiliation(s)
- Teemu Pöytäkangas
- Department of Emergency Medicine, Vaasa Central Hospital, Vaasa, Finland; Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
| | | | - Pabitra Basnyat
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Sirpa Rainesalo
- Department of Acute Medicine, Tampere University Hospital, Tampere, Finland
| | - Jukka Peltola
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Department of Neurology, Tampere University Hospital, Tampere, Finland
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Becker LL, Gratopp A, Prager C, Elger CE, Kaindl AM. Treatment of pediatric convulsive status epilepticus. Front Neurol 2023; 14:1175370. [PMID: 37456627 PMCID: PMC10343462 DOI: 10.3389/fneur.2023.1175370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Status epilepticus is one of the most common life-threatening neurological emergencies in childhood with the highest incidence in the first 5 years of life and high mortality and morbidity rates. Although it is known that a delayed treatment and a prolonged seizure can cause permanent brain damage, there is evidence that current treatments may be delayed and the medication doses administered are insufficient. Here, we summarize current knowledge on treatment of convulsive status epilepticus in childhood and propose a treatment algorithm. We performed a structured literature search via PubMed and ClinicalTrails.org and identified 35 prospective and retrospective studies on children <18 years comparing two and more treatment options for status epilepticus. The studies were divided into the commonly used treatment phases. As a first-line treatment, benzodiazepines buccal/rectal/intramuscular/intravenous are recommended. For status epilepticus treated with benzodiazepine refractory, no superiority of fosphenytoin, levetirazetam, or phenobarbital was identified. There is limited data on third-line treatments for refractory status epilepticus lasting >30 min. Our proposed treatment algorithm, especially for children with SE, is for in and out-of-hospital onset aids to promote the establishment and distribution of guidelines to address the treatment delay aggressively and to reduce putative permanent neuronal damage. Further studies are needed to evaluate if these algorithms decrease long-term damage and how to treat refractory status epilepticus lasting >30 min.
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Affiliation(s)
- Lena-Luise Becker
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Institute of Cell Biology and Neurobiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander Gratopp
- Department of Pediatric Pneumonology, Immunology and Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christine Prager
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christian E. Elger
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Beta Clinic, Bonn, Germany
| | - Angela M. Kaindl
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Institute of Cell Biology and Neurobiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Kellinghaus C. Making SENSE of what we do - How to bring evidence to clinical practice. Epilepsy Behav 2023; 140:109103. [PMID: 36739635 DOI: 10.1016/j.yebeh.2023.109103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 01/16/2023] [Indexed: 02/05/2023]
Abstract
Status epilepticus is a frequent neurological emergency. Several audits and registries have enhanced our knowledge regarding patient demography, etiology, treatment, and outcome. Several large registries have also contributed significantly to current treatment guidelines that emphasize the importance of instant and effective treatment onset. Large registries also document that deviation from these treatment guidelines is not the exception but the rule. Therefore, careful analysis of the treatment pathways as well as balanced intervention efforts are necessary to overcome the gap between knowledge and action. This paper was presented at the 8th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures held in September 2022.
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Affiliation(s)
- Christoph Kellinghaus
- Department of Neurology, Klinikum Osnabrück, Am Finkenhügel 1, 49076 Osnabrück, Germany.
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Hussein Z, Majid O, Boyd P, Aluri J, Ngo LY, Reyderman L. Intravenous Perampanel as an Interchangeable Alternative to Oral Perampanel: A Randomized, Crossover, Phase I Pharmacokinetic and Safety Study. Clin Pharmacol Drug Dev 2022; 11:878-888. [PMID: 35596529 PMCID: PMC9320958 DOI: 10.1002/cpdd.1107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 03/29/2022] [Indexed: 11/07/2022]
Abstract
Intravenous (IV) drug administration enables treatment of epilepsy when oral administration is temporarily not feasible. Perampanel is a once‐daily antiseizure medication currently available as oral formulations. Study 050 (NCT03376997) was an open‐label, randomized, single‐dose, crossover study to evaluate the interchangeability of oral and IV perampanel in healthy subjects (N = 48). Bioequivalence of single 12‐mg doses of IV (30‐, 60‐, or 90‐minute infusion) and oral perampanel, ≥6 weeks apart, was assessed. Analyses indicated bioequivalence of area under the plasma concentration–time curve extrapolated to infinity for 30‐ and 60‐minute IV infusions and oral perampanel doses (geometric mean ratio [90% confidence interval], 0.93 [0.84–1.02] and 1.03 [0.97–1.09], respectively); however, IV maximum observed drug concentration (Cmax) values were 1.35‐ to 1.61‐fold higher than Cmax. Simulated plasma concentration–time profiles using pooled pharmacokinetic data further supported oral and IV perampanel interchangeability in two scenarios: 12‐mg per day IV dosing during a temporary 7‐day switch from oral steady‐state maintenance therapy, and treatment initiation with 2‐mg perampanel. Thirty‐four (70.8%) subjects experienced treatment‐related adverse events. The IV perampanel safety profile was similar to that of oral perampanel without new safety concerns. Perampanel IV infusions may be a suitable temporary alternative to oral perampanel for treatment maintenance and/or initiation.
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Affiliation(s)
| | - Oneeb Majid
- Eisai Europe Ltd., Hatfield, Hertfordshire, UK
| | - Peter Boyd
- Eisai Europe Ltd., Hatfield, Hertfordshire, UK
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Abstract
PURPOSE The objective of our study was to evaluate the relationship between the loading dose and efficacy of lacosamide (LCM), when used in seizure clusters (SCs). METHODS A cohort of patients with SC treated with intravenous (IV)-LCM between September 2017 and September 2019 was retrospectively examined. Demographic data, type of seizure emergency, etiology, response rate, previous oral antiepileptic drugs used, total LCM loading dose, and side effects were reviewed. RESULTS Thirty-nine cases of epileptic emergencies treated with IV LCM were collected. The mean age was 59.25 years (18-88 years), and the median loading dose was 136.5 mg (100-300 mg) with a response rate in the whole population of 29.2%. Nine patients received a loading dose of 200 to 300 mg, and their response rate was 89%. Common side effects (drowsiness and dizziness) were mild. No electrocardiogram changes or other cardiovascular side effects, or unexpected side effects were seen. CONCLUSIONS In adults with SC, a loading dose of IV LCM of 200 mg or more achieved 89% response rate in this cohort. Loading doses of less than 300 mg caused mild side effects only.
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Chimakurthy AK, Ramsay RE, Sabharwal V, Menon U. Safety, tolerability, and pharmacokinetics of weight-based IV loading dose of lacosamide in the ICU. Epilepsy Behav 2021; 114:107449. [PMID: 32943331 DOI: 10.1016/j.yebeh.2020.107449] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/16/2020] [Accepted: 08/17/2020] [Indexed: 01/25/2023]
Abstract
Among the newer antiseizure medications, lacosamide (LCM) has been increasingly used for acute seizures and status epilepticus in intensive care unit (ICU). We reviewed retrospectively weight-based dosing of IV LCM in patients admitted to ICU with acute seizures and status epilepticus. We have analyzed 354/382 patient treated with IV LCM in ICU during the years 2013-2016. Data collected were age, total body weight, body mass index (BMI), loading dose, post-IV infusion LCM blood level, duration of infusion, blood pressure, heart rate, oxygen saturation, mean arterial pressures, and documented initiation of pressor agents during or within in 30 min of infusion. Larger doses >8 mg/kg of IV LCM that can be safely administered in ICU patients produce effective plasma levels of 15-20 μg/ml with relatively constant volume of distribution.
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Affiliation(s)
- Anil K Chimakurthy
- Department of Neurology, Louisiana State University Health Sciences Center, New Orleans, USA.
| | - R Eugene Ramsay
- Department of Neurology, Ochsner Neuroscience Institute, New Orleans, USA
| | - Vivek Sabharwal
- Department of Neurology, Ochsner Neuroscience Institute, New Orleans, USA
| | - Uma Menon
- Department of Neurology, Ochsner Neuroscience Institute, New Orleans, USA
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Vossler DG, Bainbridge JL, Boggs JG, Novotny EJ, Loddenkemper T, Faught E, Amengual-Gual M, Fischer SN, Gloss DS, Olson DM, Towne AR, Naritoku D, Welty TE. Treatment of Refractory Convulsive Status Epilepticus: A Comprehensive Review by the American Epilepsy Society Treatments Committee. Epilepsy Curr 2020; 20:245-264. [PMID: 32822230 PMCID: PMC7576920 DOI: 10.1177/1535759720928269] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Purpose: Established tonic–clonic status epilepticus (SE) does not stop in one-third
of patients when treated with an intravenous (IV) benzodiazepine bolus
followed by a loading dose of a second antiseizure medication (ASM). These
patients have refractory status epilepticus (RSE) and a high risk of
morbidity and death. For patients with convulsive refractory status
epilepticus (CRSE), we sought to determine the strength of evidence for 8
parenteral ASMs used as third-line treatment in stopping clinical CRSE. Methods: A structured literature search (MEDLINE, Embase, CENTRAL, CINAHL) was
performed to identify original studies on the treatment of CRSE in children
and adults using IV brivaracetam, ketamine, lacosamide, levetiracetam (LEV),
midazolam (MDZ), pentobarbital (PTB; and thiopental), propofol (PRO), and
valproic acid (VPA). Adrenocorticotropic hormone (ACTH), corticosteroids,
intravenous immunoglobulin (IVIg), magnesium sulfate, and pyridoxine were
added to determine the effectiveness in treating hard-to-control seizures in
special circumstances. Studies were evaluated by predefined criteria and
were classified by strength of evidence in stopping clinical CRSE (either as
the last ASM added or compared to another ASM) according to the 2017
American Academy of Neurology process. Results: No studies exist on the use of ACTH, corticosteroids, or IVIg for the
treatment of CRSE. Small series and case reports exist on the use of these
agents in the treatment of RSE of suspected immune etiology, severe
epileptic encephalopathies, and rare epilepsy syndromes. For adults with
CRSE, insufficient evidence exists on the effectiveness of brivaracetam
(level U; 4 class IV studies). For children and adults with CRSE,
insufficient evidence exists on the effectiveness of ketamine (level U; 25
class IV studies). For children and adults with CRSE, it is possible that
lacosamide is effective at stopping RSE (level C; 2 class III, 14 class IV
studies). For children with CRSE, insufficient evidence exists that LEV and
VPA are equally effective (level U, 1 class III study). For adults with
CRSE, insufficient evidence exists to support the effectiveness of LEV
(level U; 2 class IV studies). Magnesium sulfate may be effective in the
treatment of eclampsia, but there are only case reports of its use for CRSE.
For children with CRSE, insufficient evidence exists to support either that
MDZ and diazepam infusions are equally effective (level U; 1 class III
study) or that MDZ infusion and PTB are equally effective (level U; 1 class
III study). For adults with CRSE, insufficient evidence exists to support
either that MDZ infusion and PRO are equally effective (level U; 1 class III
study) or that low-dose and high-dose MDZ infusions are equally effective
(level U; 1 class III study). For children and adults with CRSE,
insufficient evidence exists to support that MDZ is effective as the last
drug added (level U; 29 class IV studies). For adults with CRSE,
insufficient evidence exists to support that PTB and PRO are equally
effective (level U; 1 class III study). For adults and children with CRSE,
insufficient evidence exists to support that PTB is effective as the last
ASM added (level U; 42 class IV studies). For CRSE, insufficient evidence
exists to support that PRO is effective as the last ASM used (level U; 26
class IV studies). No pediatric-only studies exist on the use of PRO for
CRSE, and many guidelines do not recommend its use in children aged <16
years. Pyridoxine-dependent and pyridoxine-responsive epilepsies should be
considered in children presenting between birth and age 3 years with
refractory seizures and no imaging lesion or other acquired cause of
seizures. For children with CRSE, insufficient evidence exists that VPA and
diazepam infusion are equally effective (level U, 1 class III study). No
class I to III studies have been reported in adults treated with VPA for
CRSE. In comparison, for children and adults with established convulsive SE
(ie, not RSE), after an initial benzodiazepine, it is likely that loading
doses of LEV 60 mg/kg, VPA 40 mg/kg, and fosphenytoin 20 mg PE/kg are
equally effective at stopping SE (level B, 1 class I study). Conclusions: Mostly insufficient evidence exists on the efficacy of stopping clinical CRSE
using brivaracetam, lacosamide, LEV, valproate, ketamine, MDZ, PTB, and PRO
either as the last ASM or compared to others of these drugs.
Adrenocorticotropic hormone, IVIg, corticosteroids, magnesium sulfate, and
pyridoxine have been used in special situations but have not been studied
for CRSE. For the treatment of established convulsive SE (ie, not RSE), LEV,
VPA, and fosphenytoin are likely equally effective, but whether this is also
true for CRSE is unknown. Triple-masked, randomized controlled trials are
needed to compare the effectiveness of parenteral anesthetizing and
nonanesthetizing ASMs in the treatment of CRSE.
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Affiliation(s)
| | - Jacquelyn L Bainbridge
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | | | - Edward J Novotny
- 384632University of Washington, Seattle, WA, USA.,Seattle Children's Center for Integrative Brain Research, Seattle, WA, USA
| | | | | | | | - Sarah N Fischer
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | - David S Gloss
- Charleston Area Medical Center, Charleston, West Virginia, VA, USA
| | | | - Alan R Towne
- 6889Virginia Commonwealth University, Richmond, VA, USA
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Willems LM, Bauer S, Jahnke K, Voss M, Rosenow F, Strzelczyk A. Therapeutic Options for Patients with Refractory Status Epilepticus in Palliative Settings or with a Limitation of Life-Sustaining Therapies: A Systematic Review. CNS Drugs 2020; 34:801-826. [PMID: 32705422 PMCID: PMC8316215 DOI: 10.1007/s40263-020-00747-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Refractory status epilepticus (RSE) represents a serious medical condition requiring early and targeted therapy. Given the increasing number of elderly or multimorbid patients with a limitation of life-sustaining therapy (LOT) or within a palliative care setting (PCS), guidelines-oriented therapy escalation options for RSE have to be omitted frequently. OBJECTIVES This systematic review sought to summarize the evidence for fourth-line antiseizure drugs (ASDs) and other minimally or non-invasive therapeutic options beyond guideline recommendations in patients with RSE to elaborate on possible treatment options for patients undergoing LOT or in a PCS. METHODS A systematic review of the literature in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, focusing on fourth-line ASDs or other minimally or non-invasive therapeutic options was performed in February and June 2020 using the MEDLINE, EMBASE and Cochrane databases. The search terminology was constructed using the name of the specific ASD or therapy option and the term 'status epilepticus' with the use of Boolean operators, e.g. "(brivaracetam) AND (status epilepticus)". The respective Medical Subject Headings (MeSH) and Emtree terms were used, if available. RESULTS There is currently no level 1, grade A evidence for the use of ASDs in RSE. The best evidence was found for the use of lacosamide and topiramate (level 3, grade C), followed by brivaracetam, perampanel (each level 4, grade D) and stiripentol, oxcarbazepine and zonisamide (each level 5, grade D). Regarding non-medicinal options, there is little evidence for the use of the ketogenic diet (level 4, grade D) and magnesium sulfate (level 5, grade D) in RSE. The broad use of immunomodulatory or immunosuppressive treatment options in the absence of a presumed autoimmune etiology cannot be recommended; however, if an autoimmune etiology is assumed, steroid pulse, intravenous immunoglobulins and plasma exchange/plasmapheresis should be considered (level 4, grade D). Even if several studies suggested that the use of neurosteroids (level 5, grade D) is beneficial in RSE, the current data situation indicates that there is formal evidence against it. CONCLUSIONS RSE in patients undergoing LOT or in a PCS represents a challenge for modern clinicians and epileptologists. The evidence for the use of ASDs in RSE beyond that in current guidelines is low, but several effective and well-tolerated options are available that should be considered in this patient population. More so than in any other population, advance care planning, advance directives, and medical ethical aspects have to be considered carefully before and during therapy.
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Affiliation(s)
- Laurent M Willems
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany.
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany.
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany.
| | - Sebastian Bauer
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Kolja Jahnke
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Martin Voss
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- Dr. Senckenberg Institute of Neuro-Oncology, Goethe University Frankfurt, University Hospital Frankfurt, Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
- Department of Neurology, Epilepsy Center Hessen, Philipps University Marburg, Marburg (Lahn), Germany
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Yadlapalli SSR, Katari NK, Manabolu Surya SB. Determination of lacosamide in human plasma by LC–MS/MS and its application to a human pharmacokinetic study. SEPARATION SCIENCE PLUS 2020. [DOI: 10.1002/sscp.202000004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
PURPOSE OF REVIEW Seizures and status epilepticus are very common diagnoses in the critically ill patient and are associated with significant morbidity and mortality. There is an abundance of research on the utility of antiseizure medications in this setting, but limited randomized-controlled trials to guide the selection of medications in these patients. This review examines the current guidelines and treatment strategies for status epilepticus and provides an update on newer antiseizure medications in the critical care settings. RECENT FINDINGS Time is brain applies to status epilepticus, with delays in treatment corresponding with worsened outcomes. Establishing standardized treatment protocols within a health system, including prehospital treatment, may lead to improved outcomes. Once refractory status epilepticus is established, continuous deep sedation with intravenous anesthetic agents should be effective. In cases, which prove highly refractory, novel approaches should be considered, with recent data suggesting multiple recently approved antiseizure medications, appropriate therapeutic options, as well as novel approaches to upregulate extrasynaptic γ-aminobutyric acid channels with brexanolone. SUMMARY Although there are many new treatments to consider for seizures and status epilepticus in the critically ill patient, the most important predictor of outcome may be rapid diagnosis and treatment. There are multiple new and established medications that can be considered in the treatment of these patients once status epilepticus has become refractory, and a multidrug regimen will often be necessary.
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Minicucci F, Ferlisi M, Brigo F, Mecarelli O, Meletti S, Aguglia U, Michelucci R, Mastrangelo M, Specchio N, Sartori S, Tinuper P. Management of status epilepticus in adults. Position paper of the Italian League against Epilepsy. Epilepsy Behav 2020; 102:106675. [PMID: 31766004 DOI: 10.1016/j.yebeh.2019.106675] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 09/30/2019] [Accepted: 10/30/2019] [Indexed: 01/15/2023]
Abstract
Since the publication of the Italian League Against Epilepsy guidelines for the treatment of status epilepticus in 2006, advances in the field have ushered in improvements in the therapeutic arsenal. The present position paper provides neurologists, epileptologists, neurointensive care specialists, and emergency physicians with updated recommendations for the treatment of adult patients with status epilepticus. The aim is to standardize treatment recommendations in the care of this patient population.
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Affiliation(s)
- Fabio Minicucci
- Epilepsy Center, Unit of Neurophysiology, Neurological Department, IRCCS San Raffaele Hospital, Milan, Italy.
| | - Monica Ferlisi
- Division of Neurology A, Azienda Ospedaliera Universitaria Integrata, Verona, Italy.
| | - Francesco Brigo
- Division of Neurology, "Franz Tappeiner" Hospital, Merano, Italy; Department of Neuroscience, Biomedicine and Movement Science, University of Verona, Verona, Italy
| | - Oriano Mecarelli
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy.
| | - Stefano Meletti
- Department of Biomedical, Metabolic and Neural Sciences, Center for Neurosciences and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy; Neurology Unit, OCB Hospital, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy.
| | - Umberto Aguglia
- Epilepsy Center, Department of Medical and Surgical Sciences Regional, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Roberto Michelucci
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Unit of Neurology, Bellaria Hospital, Bologna, Italy.
| | - Massimo Mastrangelo
- Pediatric Neurology Unit, "V. Buzzi" Children's Hospital, Pediatrics Department, ASST Fatebenefratelli Sacco, Milan, Italy.
| | - Nicola Specchio
- Department of Neuroscience, IRCCS Bambino Gesù Children's Hospital, Rome, Italy.
| | - Stefano Sartori
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy.
| | - Paolo Tinuper
- IRCCS Istituto delle Scienze Neurologiche, Bellaria Hospital, Bologna, Italy; Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy.
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Morano A, Iannone L, Palleria C, Fanella M, Giallonardo AT, De Sarro G, Russo E, Di Bonaventura C. Pharmacology of new and developing intravenous therapies for the management of seizures and epilepsy. Expert Opin Pharmacother 2018; 20:25-39. [PMID: 30403892 DOI: 10.1080/14656566.2018.1541349] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Antiepileptic drugs (AEDs) are administered orally for chronic use. Parenteral formulations might be necessary when the oral route is not feasible (e.g. an impairment of consciousness, trauma, dysphagia, gastrointestinal illness) or for treatment of seizure emergencies. At present, few intravenous (IV) formulations are available on the market. AREAS COVERED The purpose of this review is to summarize the pharmacological characteristics and clinical applications of IV medications that have been recently introduced to the armamentarium of epilepsy therapy or are currently being developed. Apart from AEDs, other compounds belonging to different pharmacological classes (e.g. diuretics, anesthetics), which have shown potential effectiveness in seizure control, are taken into consideration, and the pathophysiological premises supporting their use for epilepsy treatment are illustrated. The authors give particular focus to immunomodulatory and immunosuppressive agents, which have become the therapeutic cornerstones for immune-mediated epilepsies, despite regulatory obstacles. EXPERT OPINION In several circumstances, especially in the case of seizure-related emergencies, clinical practice seems not match literature-based evidence, and several IV AEDs are still used off-label. Strong evidence derived from randomized clinical trials (RCTs) is needed to support the effectiveness and tolerability of any therapeutic approach, however common and "accepted' it may be, in order to guarantee patient safety and well-being.
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Affiliation(s)
- Alessandra Morano
- a Neurology Unit, Department of Neurosciences, Mental Health , "Sapienza" University , Rome , Italy
| | - Luigi Iannone
- b Science of Health Department, School of Medicine , University of Catanzaro , Catanzaro , Italy
| | - Caterina Palleria
- b Science of Health Department, School of Medicine , University of Catanzaro , Catanzaro , Italy
| | - Martina Fanella
- a Neurology Unit, Department of Neurosciences, Mental Health , "Sapienza" University , Rome , Italy
| | - Anna Teresa Giallonardo
- a Neurology Unit, Department of Neurosciences, Mental Health , "Sapienza" University , Rome , Italy
| | - Giovambattista De Sarro
- b Science of Health Department, School of Medicine , University of Catanzaro , Catanzaro , Italy
| | - Emilio Russo
- b Science of Health Department, School of Medicine , University of Catanzaro , Catanzaro , Italy
| | - Carlo Di Bonaventura
- a Neurology Unit, Department of Neurosciences, Mental Health , "Sapienza" University , Rome , Italy
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Lacosamide in patients with gliomas and uncontrolled seizures: results from an observational study. J Neurooncol 2017; 136:105-114. [DOI: 10.1007/s11060-017-2628-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 10/01/2017] [Indexed: 01/05/2023]
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Strzelczyk A, Zöllner JP, Willems LM, Jost J, Paule E, Schubert-Bast S, Rosenow F, Bauer S. Lacosamide in status epilepticus: Systematic review of current evidence. Epilepsia 2017; 58:933-950. [PMID: 28295226 DOI: 10.1111/epi.13716] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The intravenous formulation of lacosamide (LCM) and its good overall tolerability and safety favor the use in status epilepticus (SE). The aim of this systematic review was to identify and evaluate studies reporting on the use of LCM in SE. METHODS We performed a systematic literature search of electronic databases using a combined search strategy from 2008 until October 2016. Using a standardized assessment form, information on the study design, methodologic framework, data sources, efficacy, and adverse events attributed to LCM were extracted from each publication and systematically reported. RESULTS In total, 522 SE episodes (51.7% female) in 486 adults and 36 children and adolescents were evaluated with an overall LCM efficacy of 57%. Efficacy was comparable between use in nonconvulsive (57%; 82/145) and generalized-convulsive (61%; 30/49; p = 0.68) SE, whereas overall success rate was better in focal motor SE (92%; 34/39, p = 0.013; p < 0.001). The efficacy with later positioning of LCM decreased from 100% to 20%. The main adverse events during treatment of SE are dizziness, abnormal vision, diplopia, and ataxia. Overall, lacosamide is well tolerated and has no clinically relevant drug-drug interactions. SIGNIFICANCE The available data regarding the use of LCM in SE are promising, with a success rate of 57%. The strength of LCM is the lack of interaction potential and the option for intravenous use in emergency situations requiring rapid uptitration.
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Affiliation(s)
- Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University, Frankfurt am Main, Germany.,Epilepsy Center Hessen and Department of Neurology, Philipps-University, Marburg, Germany
| | - Johann Philipp Zöllner
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University, Frankfurt am Main, Germany
| | - Laurent M Willems
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University, Frankfurt am Main, Germany
| | - Julie Jost
- Epilepsy Center Hessen and Department of Neurology, Philipps-University, Marburg, Germany
| | - Esther Paule
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University, Frankfurt am Main, Germany
| | - Susanne Schubert-Bast
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University, Frankfurt am Main, Germany.,Department of Neuropediatrics, Goethe-University, Frankfurt am Main, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University, Frankfurt am Main, Germany.,Epilepsy Center Hessen and Department of Neurology, Philipps-University, Marburg, Germany
| | - Sebastian Bauer
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University, Frankfurt am Main, Germany.,Epilepsy Center Hessen and Department of Neurology, Philipps-University, Marburg, Germany
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Bauer S, Willems LM, Paule E, Petschow C, Zöllner JP, Rosenow F, Strzelczyk A. The efficacy of lacosamide as monotherapy and adjunctive therapy in focal epilepsy and its use in status epilepticus: clinical trial evidence and experience. Ther Adv Neurol Disord 2017; 10:103-126. [PMID: 28382109 PMCID: PMC5367645 DOI: 10.1177/1756285616675777] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Lacosamide (LCM) is approved for anticonvulsive treatment in focal epilepsy and exhibits its function through the slow inactivation of voltage-gated sodium channels (VGSCs). LCM shows comparable efficacy with other antiepileptic drugs (AEDs) licensed in the last decade: in three randomized placebo-controlled trials, significant median seizure reduction rates of 35.2% for 200 mg/day, 36.4-39% for 400 mg/day and 37.8-40% for 600 mg/day were reported. Likewise, 50% responder rates were 38.3-41.1% for 400 mg/day and 38.1-41.2% for 600 mg/day. Similar rates were reported in post-marketing studies. The main adverse events (AEs) are dizziness, abnormal vision, diplopia and ataxia. Overall, LCM is well tolerated and has no clinically-relevant drug-drug interactions. Due to the drug's intravenous availability, its use in status epilepticus (SE) is increasing, and the available data are promising.
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Affiliation(s)
- Sebastian Bauer
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University, Frankfurt am Main, Germany Epilepsy Center Hessen and Department of Neurology, Philipps-University, Marburg, Germany
| | - Laurent M. Willems
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University, Frankfurt am Main, Germany
| | - Esther Paule
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University, Frankfurt am Main, Germany
| | - Christine Petschow
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University, Frankfurt am Main, Germany
| | - Johann Philipp Zöllner
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University, Frankfurt am Main, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University, Frankfurt am Main, Germany Epilepsy Center Hessen and Department of Neurology, Philipps-University, Marburg, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University, Frankfurt am Main, Germany Epilepsy Center Hessen and Department of Neurology, Philipps-University, Marburg, Germany
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25 years of advances in the definition, classification and treatment of status epilepticus. Seizure 2016; 44:65-73. [PMID: 27890484 DOI: 10.1016/j.seizure.2016.11.001] [Citation(s) in RCA: 128] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 11/01/2016] [Indexed: 11/24/2022] Open
Abstract
PURPOSE Status epilepticus (SE) requires not only urgent symptomatic treatment with antiepileptic drugs but also rapid identification and treatment of its cause. This narrative review summarizes the most important advances in classification and treatment of SE. METHOD Data sources included MEDLINE, EMBASE, ClinicalTrials.gov, and back tracking of references in pertinent studies, reviews, and books. RESULTS SE is now defined as "a condition resulting either from the failure of the mechanisms responsible for seizure termination or from the initiation of mechanisms, which lead to abnormally, prolonged seizures (after time point t1). It is a condition, which can have long-term consequences (after time point t2), including neuronal death, neuronal injury, and alteration of neuronal networks, depending on the type and duration of seizures." A new diagnostic classification system of SE introduces four axes: semiology, aetiology, EEG correlates, and age. For the acute treatment intravenous benzodiazepines (lorazepam, diazepam, clonazepam) and intramuscular midazolam appear as most effective treatments for early SE. In children, buccal or intranasal midazolam are useful alternatives. In established SE intravenous antiepileptic drugs (phenytoin, valproate, levetiracetam, phenobarbital, and lacosamide) are in use. Treatment options in refractory SE are intravenous anaesthetics; ketamine, magnesium, steroids and other drugs have been used in super-refractory SE with variable outcomes. CONCLUSION Over the past 25 years major advances in definition, classification and understanding of its mechanisms have been achieved. Despite this up to 40% of patients in early status cannot be controlled with first line drugs. The treatment of super-refractory status is still an almost evidence free zone.
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