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Nilo A, Vogrig A, Belluzzo M, Lettieri C, Verriello L, Valente M, Pauletto G. Efficacy of Perampanel in Refractory and Super-Refractory Status Epilepticus with Suspected Inflammatory Etiology: A Case Series. Pharmaceuticals (Basel) 2023; 17:28. [PMID: 38256862 PMCID: PMC10819860 DOI: 10.3390/ph17010028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/30/2023] [Accepted: 12/19/2023] [Indexed: 01/24/2024] Open
Abstract
(1) Background: Increasing evidence supports the anti-inflammatory and neuroprotective role of perampanel (PER), mediated by decreased expression of pro-inflammatory cytokines and by interference with apoptosis processes. Therefore, the use of PER to treat status epilepticus (SE) with suspected inflammatory etiology is appealing and deserves further investigation. (2) Methods: We retrospectively analyzed seven patients (five F, two M; median age: 62 years) with refractory and super-refractory SE due to a probable or defined inflammatory etiology and treated with PER. (3) Results: PER was administered as the third (4/7) or fourth drug (3/7), with a median loading dose of 32 mg/day (range: 16-36 mg/day) and a median maintenance dose of 10 mg/day (range: 4-12 mg/day). In five cases, SE was focal, while in two patients, it was generalized. SE was caused by systemic inflammation in three patients, while in the other four subjects, it was recognized to have an autoimmune etiology. SE resolution was observed after PER administration in all cases, particularly within 24 h in the majority of patients (4/7, 57.1%). (4) Conclusions: Our data support the efficacy of PER in treating SE when first- and second-line ASMs have failed and suggest a possible earlier use in SE cases that are due to inflammatory/autoimmune etiology.
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Affiliation(s)
- Annacarmen Nilo
- Clinical Neurology Unit, Department of Head, Neck and Neurosciences, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy; (A.V.); (C.L.); (M.V.)
- Department of Medicine, University of Udine, 33100 Udine, Italy
| | - Alberto Vogrig
- Clinical Neurology Unit, Department of Head, Neck and Neurosciences, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy; (A.V.); (C.L.); (M.V.)
- Department of Medicine, University of Udine, 33100 Udine, Italy
| | - Marco Belluzzo
- Neurology Unit, Department of Head, Neck and Neurosciences, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy; (M.B.); (L.V.); (G.P.)
| | - Christian Lettieri
- Clinical Neurology Unit, Department of Head, Neck and Neurosciences, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy; (A.V.); (C.L.); (M.V.)
| | - Lorenzo Verriello
- Neurology Unit, Department of Head, Neck and Neurosciences, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy; (M.B.); (L.V.); (G.P.)
| | - Mariarosaria Valente
- Clinical Neurology Unit, Department of Head, Neck and Neurosciences, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy; (A.V.); (C.L.); (M.V.)
- Department of Medicine, University of Udine, 33100 Udine, Italy
| | - Giada Pauletto
- Neurology Unit, Department of Head, Neck and Neurosciences, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy; (M.B.); (L.V.); (G.P.)
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Lattanzi S, Giovannini G, Orlandi N, Brigo F, Trinka E, Meletti S. How much refractory is 'refractory status epilepticus'? A retrospective study of treatment strategies and clinical outcomes. J Neurol 2023; 270:6133-6140. [PMID: 37587268 DOI: 10.1007/s00415-023-11929-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 07/29/2023] [Accepted: 08/09/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND AND PURPOSE This study aimed to evaluate whether differences in clinical outcomes exist according to treatments received and seizure activity resolution in patients with refractory status epilepticus (RSE). METHODS Consecutive episodes of non-hypoxic status epilepticus (SE) in patients ≥ 14 years old were included. Episodes of RSE were stratified in: (i) SE persistent despite treatment with first-line therapy with benzodiazepines and one second-line treatment with antiseizure medications (ASMs), but responsive to successive treatments with ASMs (RSE-rASMs); (ii) SE persistent despite treatment with first-line therapy with benzodiazepines and successive treatment with one or more second-line ASMs, but responsive to anesthetic drugs [RSE-rGA (general anesthesia)]. Study endpoints were mortality during hospitalization and worsening of modified Rankin Scale (mRS) at discharge. RESULTS Status epilepticus was responsive in 298 (54.1%), RSE-rASMs in 152 (27.6%), RSE-rGA in 46 (8.3%), and super-refractory (SRSE) in 55 (10.0%) out of 551 included cases. Death during hospitalization occurred in 98 (17.8%) and worsening of mRS at discharge in 287 (52.1%) cases. Multivariable analyses revealed increased odds of in-hospital mortality with RSE-rGA (odds ratio [OR] 3.05, 95% confidence interval [CI] 1.27-7.35) and SRSE (OR 3.83, 95%. CI 1.73-8.47), and increased odds of worsening of mRS with RSE-rASMs (OR 2.06, 95% CI 1.28-3.31), RSE-rGA (OR 4.44, 95% CI 1.97-10.00), and SRSE (OR 13.81, 95% CI 5.34-35.67). CONCLUSIONS In RSE, varying degrees of refractoriness may be defined and suit better the continuum spectrum of disease severity and the heterogeneity of SE burden and prognosis.
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Affiliation(s)
- Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Via Conca 71, 60020, Ancona, Italy.
| | | | - Niccolò Orlandi
- Neurology Unit, OCB Hospital, AOU Modena, Modena, Italy
- Department of Biomedical, Metabolic and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Via Giardini, 1355, Ospedale Civile S. Agostino Estense, 41126, Modena, Italy
| | - Francesco Brigo
- Division of Neurology, "Franz Tappeiner" Hospital, Merano, BZ, Italy
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
- Center for Cognitive Neuroscience, Salzburg, Austria
- Public Health, Health Services Research and HTA, University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Stefano Meletti
- Neurology Unit, OCB Hospital, AOU Modena, Modena, Italy.
- Department of Biomedical, Metabolic and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Via Giardini, 1355, Ospedale Civile S. Agostino Estense, 41126, Modena, Italy.
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Mantoan Ritter L, Selway R. Perspective: Vagal nerve stimulation in the treatment of new-onset refractory status epilepticus. Front Neurol 2023; 14:1172898. [PMID: 37153661 PMCID: PMC10157031 DOI: 10.3389/fneur.2023.1172898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 03/30/2023] [Indexed: 05/10/2023] Open
Abstract
Introduction Resistance to drug therapy is a major hurdle in new-onset refractory status epilepticus (NORSE) treatment and there is urgent need to develop new treatment approaches. Non-drug approaches such as neuromodulation offer significant benefits and should be investigated as new adjunct treatment modalities. An important unanswered question is whether desynchronizing networks by vagal nerve stimulation (VNS) may improve seizure control in NORSE patients. Main text We present a summary of published NORSE cases treated with VNS and our own data, discuss possible mechanisms of action, review VNS implantation timing, stimulation setting titration protocols and outcomes. Further, we propose avenues for future research. Discussion We advocate for consideration of VNS for NORSE both in early and late stages of the presentation and hypothesize a possible additional benefit from implantation in the acute phase of the disease. This should be pursued in the context of a clinical trial, harmonizing inclusion criteria, accuracy of documentation and treatment protocols. A study planned within our UK-wide NORSE-UK network will answer the question if VNS may confer benefits in aborting unremitting status epilepticus, modulate ictogenesis and reduce long-term chronic seizure burden.
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Affiliation(s)
- Laura Mantoan Ritter
- Epilepsy Centre, Clinical Neurosciences Department, King's College NHS Foundation Trust, London, United Kingdom
- Maurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
- *Correspondence: Laura Mantoan Ritter
| | - Richard Selway
- Epilepsy Centre, Clinical Neurosciences Department, King's College NHS Foundation Trust, London, United Kingdom
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Recurrent Status Epilepticus: clinical features and recurrence risk in an adult population. Seizure 2022; 97:1-7. [DOI: 10.1016/j.seizure.2022.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/21/2022] [Accepted: 02/23/2022] [Indexed: 11/22/2022] Open
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Rösche J, Schade B. Levetiracetam as second-line treatment of status epilepticus – which dose should be applied? JOURNAL OF EPILEPTOLOGY 2021. [DOI: 10.21307/jepil-2021-001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Pharmacotherapy for Nonconvulsive Seizures and Nonconvulsive Status Epilepticus. Drugs 2021; 81:749-770. [PMID: 33830480 DOI: 10.1007/s40265-021-01502-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2021] [Indexed: 12/22/2022]
Abstract
Most seizures in critically ill patients are nonconvulsive. A significant number of neurological and medical conditions can be complicated by nonconvulsive seizures (NCSs) and nonconvulsive status epilepticus (NCSE), with brain infections, hemorrhages, global hypoxia, sepsis, and recent neurosurgery being the most prominent etiologies. Prolonged NCSs and NCSE can lead to adverse neurological outcomes. Early recognition requires a high degree of suspicion and rapid and appropriate duration of continuous electroencephalogram (cEEG) monitoring. Although high quality research evaluating treatment with antiseizure medications and long-term outcome is still lacking, it is probable that expeditious pharmacological management of NCSs and NCSE may prevent refractoriness and further neurological injury. There is limited evidence on pharmacotherapy for NCSs and NCSE, although a few clinical trials encompassing both convulsive and NCSE have demonstrated similar efficacy of different intravenous (IV) antiseizure medications (ASMs), including levetiracetam, valproate, lacosamide and fosphenytoin. The choice of specific ASMs lies on tolerability and safety since critically ill patients frequently have impaired renal and/or hepatic function as well as hematological/hemodynamic lability. Treatment frequently requires more than one ASM and occasionally escalation to IV anesthetic drugs. When multiple ASMs are required, combining different mechanisms of action should be considered. There are several enteral ASMs that could be used when IV ASM options have been exhausted. Refractory NCSE is not uncommon, and its treatment requires a very judicious selection of ASMs aiming at reducing seizure burden along with management of the underlying condition.
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Orlandi N, Bartolini E, Audenino D, Coletti Moja M, Urso L, d'Orsi G, Pauletto G, Nilo A, Zinno L, Cappellani R, Zummo L, Giordano A, Dainese F, Nazerian P, Pescini F, Beretta S, Dono F, Gaudio LD, Ferlisi M, Marino D, Piccioli M, Renna R, Rosati E, Rum A, Strigaro G, Giovannini G, Meletti S, Cavalli SM, Contento M, Cottone S, Di Claudio MT, Florindo I, Guadagni M, Kiferle L, Lazzaretti D, Lazzari M, Coco DL, Pradella S, Rikani K, Rodorigo D, Sabetta A, Sicurella L, Tontini V, Turchi G, Vaudano AE, Zanoni T. Intravenous brivaracetam in status epilepticus: A multicentric retrospective study in Italy. Seizure 2021; 86:70-76. [PMID: 33561784 DOI: 10.1016/j.seizure.2021.01.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 12/31/2020] [Accepted: 01/13/2021] [Indexed: 10/22/2022] Open
Abstract
PURPOSE to evaluate the use, effectiveness, and adverse events of intravenous brivaracetam (BRV) in status epilepticus (SE). METHODS a retrospective multicentric study involving 24 Italian neurology units was performed from March 2018 to June 2020. A shared case report form was used across participating centres to limit biases of retrospective data collection. Diagnosis and classification of SE followed the 2015 ILAE proposal. We considered a trial with BRV a success when it was the last administered drug prior the clinical and/or EEG resolution of seizures, and the SE did not recur during hospital observation. In addition, we considered cases with early response, defined as SE resolved within 6 h after BRV administration. RESULTS 56 patients were included (mean age 62 years; 57 % male). A previous diagnosis of epilepsy was present in 21 (38 %). Regarding SE etiology classification 46 % were acute symptomatic, 18 % remote and 16 % progressive symptomatic. SE episodes with prominent motor features were the majority (80 %). BRV was administered as first drug after benzodiazepine failure in 21 % episodes, while it was used as the second or the third (or more) drug in the 38 % and 38 % of episodes respectively. The median loading dose was 100 mg (range 50-300 mg). BRV was effective in 32 cases (57 %). An early response was documented in 22 patients (39 % of the whole sample). The use of the BRV within 6 h from SE onset was independently associated to an early SE resolution (OR 32; 95 % CI 3.39-202; p = 0.002). No severe treatment emergent adverse events were observed. CONCLUSION BRV proved to be useful and safe for the treatment of SE. Time to seizures resolution appears shorter when it is administered in the early phases of SE.
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Affiliation(s)
- Niccolò Orlandi
- Department of Biomedical, Metabolic and Neural Sciences, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy; Neurology Department, OCB Hospital, AOU Modena, Italy
| | - Emanuele Bartolini
- Neurology Unit, Nuovo Ospedale Santo Stefano, USL Centro Toscana, Prato, Italy
| | | | | | - Lidia Urso
- Neurology and Stroke Unit, PO. S. Antonio Abate, Trapani, Italy
| | - Giuseppe d'Orsi
- Epilepsy Centre - S.C. Neurologia Universitaria, Policlinico Riuniti, Foggia, Italy
| | - Giada Pauletto
- Neurology Unit, Department of Neurosciences, Santa Maria Della Misericordia University Hospital, ASUFC, Udine, Italy
| | - Annacarmen Nilo
- Clinical Neurology Unit, Department of Neurosciences, Santa Maria Della Misericordia University Hospital, ASUFC, Udine, Italy
| | - Lucia Zinno
- Neurology Unit, Maggiore Hospital, AOU Parma, Italy
| | | | - Leila Zummo
- Neurology and Stroke Unit, P.O. ARNAS-Civico, Palermo, Italy
| | | | - Filippo Dainese
- Epilepsy Centre, UOC Neurology, ULSS3 Serenissima, Venice, Italy
| | - Peiman Nazerian
- Department of Emergency Medicine, Careggi University Hospital, Florence, Italy
| | | | - Simone Beretta
- Department of Neurology, Ospedale San Gerardo ASST Monza, University of Milano Bicocca, Italy
| | - Fedele Dono
- Department of Neuroscience, Imaging and Clinical Science, University "G. D'Annunzio" of Chieti-Pescara, Italy
| | | | | | - Daniela Marino
- Epilepsy Center, Neurology Unit, Department of Cardio-neuro-vascular Sciences, San Donato Hospital, Arezzo, Italy
| | | | - Rosaria Renna
- Neurological Clinic and Stroke Unit - "A. Cardarelli" Hospital, Naples, Italy
| | - Eleonora Rosati
- Neurology Unit 2, Careggi University Hospital, Florence, Italy
| | - Adriana Rum
- Neurology and Neurophysiopatology Unit, Aurelia Hospital, Rome, Italy
| | | | | | - Stefano Meletti
- Department of Biomedical, Metabolic and Neural Sciences, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy; Neurology Department, OCB Hospital, AOU Modena, Italy.
| | | | | | | | | | | | | | - Martina Guadagni
- Epilepsy Center, Neurology Unit, Department of Cardio-neuro-vascular Sciences, San Donato Hospital, Arezzo, Italy
| | - Lorenzo Kiferle
- Neurology Unit, Nuovo Ospedale Santo Stefano, USL Centro Toscana, Prato, Italy
| | - Delia Lazzaretti
- Department of Emergency Medicine, Careggi University Hospital, Florence, Italy
| | | | - Daniele Lo Coco
- Neurology and Stroke Unit, P.O. ARNAS-Civico, Palermo, Italy
| | - Silvia Pradella
- Neurology Unit, Nuovo Ospedale Santo Stefano, USL Centro Toscana, Prato, Italy
| | | | - Davide Rodorigo
- Department of Neuroscience, Imaging and Clinical Science, University "G. D'Annunzio" of Chieti-Pescara, Italy
| | - Annarita Sabetta
- Epilepsy Centre - S.C. Neurologia Universitaria, Policlinico Riuniti, Foggia, Italy
| | - Luigi Sicurella
- Neurology and Stroke Unit, PO. S. Antonio Abate, Trapani, Italy
| | | | - Giulia Turchi
- Neurology Department, OCB Hospital, AOU Modena, Italy
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DeMott JM, Slocum GW, Gottlieb M, Peksa GD. Levetiracetam vs. phenytoin as 2nd-line treatment for status epilepticus: A systematic review and meta-analysis. Epilepsy Behav 2020; 111:107286. [PMID: 32707535 DOI: 10.1016/j.yebeh.2020.107286] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/21/2020] [Accepted: 06/21/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The objective of the study was to perform a systematic review and meta-analysis to evaluate the efficacy and safety of levetiracetam (LEV) or phenytoin (PHT) as second-line treatment for status epilepticus (SE). METHODS PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Latin American and Caribbean Health Sciences Literature (LILACS), Scopus, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and Google Scholar were assessed for prospective randomized trials comparing LEV with PHT as second-line treatment of SE published from inception until December 18th, 2019. The primary outcome was seizure cessation. Data were analyzed using a random-effects model. Quality analysis was performed using version 2 of the Cochrane risk-of-bias tool (RoB 2). The study protocol was registered on PROSPERO (CRD42020136417). RESULTS Nine studies with a total of 1732 patients were included. Overall, seizure cessation occurred in 657 of 887 (74%) of patients in the LEV group and 600 of 845 (71%) in the PHT group. Treatment success did not differ significantly between groups, and the relative risk (RR) was 1.05 (95% confidence interval (CI): 0.98-1.12; I2 = 53%). Six of the studies were at low risk of bias, one study had some risk, and two studies had high risk. CONCLUSIONS The use of LEV or PHT as second-line agents after benzodiazepine (BZD) for the treatment of SE was not associated with a difference in seizure cessation. Because there are minimal differences in efficacy at this time, clinicians should consider alternative factors when deciding on an antiepileptic drug (AED).
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Affiliation(s)
- Joshua M DeMott
- Department of Pharmacy, Rush University Medical Center, Chicago, IL, USA; Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA.
| | - Giles W Slocum
- Department of Pharmacy, Rush University Medical Center, Chicago, IL, USA; Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Gary D Peksa
- Department of Pharmacy, Rush University Medical Center, Chicago, IL, USA; Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
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Orlandi N, Giovannini G, Rossi J, Cioclu MC, Meletti S. Clinical outcomes and treatments effectiveness in status epilepticus resolved by antiepileptic drugs: A five-year observational study. Epilepsia Open 2020; 5:166-175. [PMID: 32524042 PMCID: PMC7278543 DOI: 10.1002/epi4.12383] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 02/09/2020] [Accepted: 02/11/2020] [Indexed: 12/29/2022] Open
Abstract
Objective To evaluate clinical outcomes and treatment effectiveness of status epilepticus finally resolved by nonbenzodiazepine antiepileptic drugs (AEDs). Methods All consecutive SE episodes observed from September 1, 2013, to September 1, 2018, and resolved by AEDs were considered. Diagnosis and classification of SE followed the 2015 ILAE proposal. Nonconvulsive status (NCSE) diagnosis was confirmed according to the Salzburg EEG criteria. The modified Rankin Scale and deaths at 30 days from onset were used to evaluate outcomes. Results A total of 277 status episodes (mean age 71 years; 61% female) were treated and resolved by antiepileptic drugs after 382 treatment trials. 68% of the SE resolved after AED use as first/second treatment line, while subsequent trials with AEDs gave an additional 32% resolution. A return to baseline conditions was observed in 48% of the patients, while overall mortality was 19% without significant changes across the study years. Mortality was higher in NCSE than in convulsive SE (22.5% vs 12.9%; P < .05), while mortality did not differ in SE episodes resolved by a first/second AED trial (17.2%) versus SE resolved by successive treatment trials (18.9%). The resolution rate of intravenous AEDs was 82% for valproate, 77% for lacosamide, 71% for phenytoin, and 62% for levetiracetam. No significant differences were found in head-to-head comparison, but for the valproate-levetiracetam one that was related to NCSE episodes in which valproate resulted to be effective in 86% of the trials while levetiracetam in 62% (P < .002). Significance A high short-term mortality, stable over time, was observed in SE despite resolution of seizures, especially in SE with nonconvulsive semiology. Comparative AED efficacy showed no significant differences except for higher resolution rate for valproate versus levetiracetam in NCSE.
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Affiliation(s)
- Niccolò Orlandi
- Neurology Unit OCB Hospital Azienda Ospedaliera-Universitaria Modena Italy.,Department of Biomedical, Metabolic and Neural Science University of Modena and Reggio Emilia Modena Italy
| | - Giada Giovannini
- Neurology Unit OCB Hospital Azienda Ospedaliera-Universitaria Modena Italy.,Department of Biomedical, Metabolic and Neural Science University of Modena and Reggio Emilia Modena Italy
| | - Jessica Rossi
- Neurology Unit OCB Hospital Azienda Ospedaliera-Universitaria Modena Italy.,Department of Biomedical, Metabolic and Neural Science University of Modena and Reggio Emilia Modena Italy
| | - Maria Cristina Cioclu
- Neurology Unit OCB Hospital Azienda Ospedaliera-Universitaria Modena Italy.,Department of Biomedical, Metabolic and Neural Science University of Modena and Reggio Emilia Modena Italy
| | - Stefano Meletti
- Neurology Unit OCB Hospital Azienda Ospedaliera-Universitaria Modena Italy.,Department of Biomedical, Metabolic and Neural Science University of Modena and Reggio Emilia Modena Italy
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Dibué-Adjei M, Brigo F, Yamamoto T, Vonck K, Trinka E. Vagus nerve stimulation in refractory and super-refractory status epilepticus - A systematic review. Brain Stimul 2019; 12:1101-1110. [PMID: 31126871 DOI: 10.1016/j.brs.2019.05.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 05/06/2019] [Accepted: 05/08/2019] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Refractory status epilepticus (RSE) is the persistence of status epilepticus despite second-line treatment. Super-refractory SE (SRSE) is characterized by ongoing status despite 48 h of anaesthetic treatment. Due to the high case fatality in RSE of 16-39%, off label treatments without strong evidence of efficacy in RSE are often administered. In single case-reports and small case series totalling 28 patients, acute implantation of VNS in RSE was associated with 76% and 26% success rate in generalized and focal RSE respectively. We performed an updated systematic review of the literature on efficacy of VNS in RSE/SRSE by including all reported patients. METHODS We systematically searched EMBASE, CENTRAL, Opengre.eu, and ClinicalTrials.gov, and PubMed databases to identify studies reporting the use of VNS for RSE and/or SRSE. We also searched conference abstracts from AES and ILAE meetings. RESULTS 45 patients were identified in total of which 38 were acute implantations of VNS in RSE/SRSE. Five cases had VNS implantation for epilepsia partialis continua, one for refractory electrical status epilepticus in sleep and one for acute encephalitis with refractory repetitive focal seizures. Acute VNS implantation was associated with cessation of RSE/SRSE in 74% (28/38) of acute cases. Cessation did not occur in 18% (7/38) of cases and four deaths were reported (11%); all of them due to the underlying disease and unlikely related to VNS implantation. Median duration of the RSE/SRSE episode pre and post VNS implantation was 18 days (range: 3-1680 days) and 8 days (range: 3-84 days) respectively. Positive outcomes occurred in 82% (31/38) of cases. CONCLUSION VNS can interrupt RSE and SRSE in 74% of patients; data originate from reported studies classified as level IV and the risk for reporting bias is high. Further prospective studies are warranted to investigate acute VNS in RSE and SRSE.
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Affiliation(s)
- Maxine Dibué-Adjei
- LivaNova Deutschland GmbH, LivaNova PLC-owned Subsidiary, Lindberghstraße 25, 80939, Munich, Germany; Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstraße 5, D-40225, Düsseldorf, Germany.
| | - Francesco Brigo
- Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy; Department of Neurology, Franz Tappeiner Hospital, Merano, Italy
| | - Takamichi Yamamoto
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Kristl Vonck
- Brain Research Team, Department of Neurology, Ghent University, Ghent, Belgium
| | - Eugen Trinka
- Department of Neurology, Christian-Doppler University Hospital, Paracelsus Medical University, Centre for Cognitive Neuroscience, Salzburg, Austria; Institute of Public Health, Medical Decision Making and HTA, UMIT, Private University for Health Sciences, Medical Informatics and Technology, Hall in Tyrol, Austria
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Farrokh S, Bon J, Erdman M, Tesoro E. Use of Newer Anticonvulsants for the Treatment of Status Epilepticus. Pharmacotherapy 2019; 39:297-316. [PMID: 30723940 DOI: 10.1002/phar.2229] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Status epilepticus (SE) has a high mortality rate and is one of the most common neurologic emergencies. Fast progression of this neurologic emergency and lack of response to traditional antiepileptic drugs (AEDs) in most cases has challenged clinicians to use new agents. This article evaluates the efficacy and safety of AEDs released to the market after 2000 for SE, refractory status epilepticus (RSE), and super-refractory status epilepticus (SRSE). The PubMed database was searched for clinical trials published between January 2000 and July 2018 using the search terms status epilepticus, refractory status epilepticus, super refractory status epilepticus, brivaracetam, clobazam, cannabidiol, eslicarbazepine, lacosamide, perampanel, rufinamide, stiripentol, and zonisamide. Trials that evaluated these agents in adults with SE, RSE, and SRSE were included. Brivaracetam use was identified in two retrospective reviews with success rates of 27% and 57%. One unsuccessful case report of cannabidiol use in SE was found. Four clobazam studies were identified in SE and RSE with success rates ranging from 25-100%. No evidence for the use of eslicarbazepine and zonisamide was found. Using the search terms for lacosamide identified 38 articles: 1 systematic review, 5 prospective studies, 15 retrospective reviews, and 17 case reports. Success rates and dosing varied, but studies that included focal or partial types of SE showed higher success rates. Five articles were identified regarding perampanel use in this setting. Three were retrospective reviews with success rates ranging from 17-60%, and two were case reports. Only one case report regarding the use of rufinamide was found; rufinamide titrated up to 4.4 mg/day allowed discontinuation of barbiturate and clobazam. One case report and two case series of stiripentol were found with reported efficacy between 60% and 100% in SRSE. Evidence is currently insufficient to support the use of these agents in this setting.
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Affiliation(s)
- Salia Farrokh
- Johns Hopkins Hospital, Division of Critical Care and Surgery Pharmacy, Baltimore, Maryland
| | - John Bon
- Department of Pharmacy, Summa Health System, Akron, Ohio
| | | | - Eljim Tesoro
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois
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Perrenoud M, André P, Buclin T, Decosterd LA, Rossetti AO, Novy J. Levetiracetam circulating concentrations and response in status epilepticus. Epilepsy Behav 2018; 88:61-65. [PMID: 30241055 DOI: 10.1016/j.yebeh.2018.08.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 08/20/2018] [Accepted: 08/20/2018] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Intravenous levetiracetam (LEV) is broadly used in the treatment of status epilepticus (SE). A loading dose is usually infused, aiming to reach quickly the range of plasma concentrations considered as therapeutic (12-46 mg/l). The aim of the study was to evaluate the response to LEV in SE, correlated exposure assessed by plasma concentration monitoring, as well as calculated exposure parameters. MATERIALS & METHODS We retrospectively analyzed a SE registry, including patients since 2015 with at least one available LEV plasma level measured less than 36 h after loading. A Bayesian maximum likelihood approach based on a population pharmacokinetic model was used to estimate LEV exposure parameters. We compared plasma levels and pharmacokinetics parameter estimates between responders and nonresponders. Therapeutic response was defined as SE cessation within 24 h following LEV introduction without a need for additional antiepileptic drug (AED). RESULTS We included 29 patients (45 plasma levels). Variability was salient in LEV loading doses (ranging between 17 and 38 mg/kg) and monitoring practice. There was no difference in median plasma concentrations (19.5 versus 21.5 mg/l; p = 0.71), median estimated LEV exposure (25.8 versus 37.0 mg/l; p = 0.61), peak (30.4 versus 41.5 mg/l; p = 0.36), or residual levels after loading dose (14.4 versus 20.5 mg/l; p = 0.07) between responders and nonresponders. CONCLUSIONS Levetiracetam exposure does not seem to differ significantly between responders and nonresponders; greater exposure was not associated with better outcome. Loading doses of 30 mg/kg seem, however, appropriate to quickly reach the target exposure level. The short LEV half-life makes standardized sampling measurement necessary to obtain directly interpretable LEV levels.
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Affiliation(s)
- Matthieu Perrenoud
- Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Switzerland
| | - Pascal André
- Division of Clinical Pharmacology, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Switzerland
| | - Thierry Buclin
- Division of Clinical Pharmacology, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Switzerland
| | - Laurent A Decosterd
- Clinical Pharmacology Laboratory, Laboratory Department, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Switzerland
| | - Andrea O Rossetti
- Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Switzerland
| | - Jan Novy
- Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Switzerland.
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Santamarina E, González-Cuevas M, Toledo M, Jiménez M, Becerra JL, Quílez A, Suller A, Mauri JA, Fernández Á, Marinas A, Quintana M, Puig XS. Intravenous lacosamide (LCM) in status epilepticus (SE): Weight-adjusted dose and efficacy. Epilepsy Behav 2018; 84:93-98. [PMID: 29758445 DOI: 10.1016/j.yebeh.2018.04.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 04/16/2018] [Accepted: 04/28/2018] [Indexed: 01/15/2023]
Abstract
BACKGROUND Some studies suggest higher efficacy of lacosamide (LCM) in status epilepticus (SE) with higher loading doses; however, this weight-adjusted dose has not been evaluated. OBJECTIVE The objective was to evaluate the relationship between loading weight-adjusted dose and efficacy of LCM in SE. METHODS A group of patients with SE treated with LCM from Spanish hospitals was examined retrospectively. Demographic data, type of SE, etiology, response rate, last antiepileptic drug (AED) used, treatment line in which LCM was used, total loading dose, and weight-adjusted dose were collected. RESULTS One hundred sixty-five cases of SE were collected; 87 (52.7%) patients had nonconvulsive SE. Mean age was 64.2 ± 17.2 and 60.6% (n = 100) were men. Regarding etiology, SE was considered as acute symptomatic in 85 (51.5%), remote symptomatic in 51 (30.9%), progressive symptomatic in 10 (6.1%), and cryptogenic in 19 (11.5%). Lacosamide was used as the third drug in 46.1%, and as a second option in 28%. In 115 patients, clonazepam had been used as the first option, and no benzodiazepines had been administered in the remaining 50. The median loading dose was 400 mg (100-600 mg), and the weight-adjusted dose was 5 mg/kg (3-6 mg/kg). The response rate was 63.3%, and 55.1% responded within the first 12 h. Efficacy was significantly higher in patients who had taken benzodiazepines at LCM loading doses >5.3 mg/kg (p = 0.006). This relationship was maintained independent of using other concomitant AEDs. However, if benzodiazepines were not taken, this relationship was not found. CONCLUSIONS In adults with benzodiazepine-resistant SE, the response rate to LCM was higher, with weight-adjusted doses above 5.3 mg/kg.
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Affiliation(s)
| | | | - Manuel Toledo
- Epilepsy Unit, Hospital Vall d'Hebron, Barcelona, Spain
| | - Marta Jiménez
- Epilepsy Unit, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Juan Luis Becerra
- Epilepsy Unit, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Alex Quílez
- Department of Neurology, Hospital Arnau de Vilanova, Lleida, Spain
| | - Ana Suller
- Department of Neurology, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - J A Mauri
- Department of Neurology, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Ángel Fernández
- Department of Neurology, Hospital del Bierzo Ponferrada, Ponferrada, León, Spain
| | - Ainhoa Marinas
- Epilepsy Unit, Hospital Universitario Cruces, Baracaldo Vizcaya, Spain
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Selioutski O, Grzesik K, Vasilyeva ON, Hilmarsson Á, Fessler AJ, Liu L, Gross RA. Evaluation of phenytoin serum levels following a loading dose in the acute hospital setting. Seizure 2017; 52:199-204. [PMID: 29073585 PMCID: PMC5846464 DOI: 10.1016/j.seizure.2017.10.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/21/2017] [Accepted: 10/07/2017] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Due to the complex pharmacokinetic profiles of phenytoin (PHT) and fosphenytoin (FOS), achieving sustained, targeted serum PHT levels in the first day of use is challenging. METHODS A population based approach was used to analyze total serum PHT (tPHT) level within 2-24h of PHT/FOS loading with or without supplementary maintenance or additional loading doses among PHT-naïve patients in the acute hospital setting. Adequate tPHT serum level was defined as ≥20μg/mL. RESULTS Among 494 patients with 545 tPHT serum levels obtained in the first 2-24h after the loading dose (LD), tPHT serum levels of either CONCLUSION Close laboratory surveillance and PHT/FOS dose adjustments are recommended to ensure adequate and sustained tPHT serum levels early in treatment. Free serum PHT level is the preferred method of drug monitoring.
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Affiliation(s)
- Olga Selioutski
- Department of Neurology, Strong Epilepsy Center, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Katherine Grzesik
- Department of Biostatistics, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Olga N Vasilyeva
- Department of Pharmacy, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | | | - A James Fessler
- Department of Neurology, Strong Epilepsy Center, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Lynn Liu
- Department of Neurology, Strong Epilepsy Center, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Robert A Gross
- Department of Neurology, Strong Epilepsy Center, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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