The short-term impact of adjunctive tiagabine on health-related quality of life

Health-related quality of life in double-blind Phase III studies of brivaracetam as adjunctive therapy of focal seizures: A pooled, post-hoc analysis

PURPOSE

The effect of adjunctive brivaracetam on health-related quality of life (HRQoL) was assessed in a post-hoc analysis using pooled data from three randomized, double-blind, placebo-controlled Phase III studies in patients with refractory focal seizures (NCT00490035, NCT00464269, and NCT01261325).

METHODS

The Patient-Weighted Quality of Life in Epilepsy Questionnaire (QOLIE-31-P) was completed at randomization, and weeks 4, 8 (in two of three studies), and 12 (end of the treatment period). Mean change from baseline to week 12 or early discontinuation, and percentage of patients with clinically meaningful improvement were reported for the placebo and brivaracetam 50, 100, and 200mg/day groups.

RESULTS

At baseline, mean QOLIE-31-P scores were similar between treatment groups. At week 12 or early discontinuation, mean (standard deviation) changes from baseline in QOLIE-31-P total score were 2.8 (12.7), 3.0 (14.0), 2.4 (14.0), and 3.0 (12.1) points for the placebo and brivaracetam 50, 100, and 200mg/day groups, respectively, indicating HRQoL improved slightly over time during the treatment period, but was similar for placebo and brivaracetam groups. All subscale score changes were positive, indicating stable or improved HRQoL over time. The brivaracetam 100 and 200mg/day groups showed the largest differences compared with placebo in Seizure Worry subscale scores (7.3 and 8.8 vs. 5.0 points). Approximately 40% of patients had improvements in QOLIE-31-P scores beyond the Minimal Important Change (MIC) thresholds. The subgroup of ≥50% focal seizure frequency responders had higher improvements for all treatment arms and all subscales than for those in the overall pooled population.

CONCLUSION

In this post-hoc analysis, adjunctive brivaracetam treatment was shown to be associated with stable or improving overall HRQoL over time, similar to placebo, with modest improvements in subscales sensitive to efficacy, and no deterioration in subscales sensitive to tolerability. These results reflect the known efficacy and tolerability profile of brivaracetam.

Tiagabine in clinical practice: effects on seizure control and behavior

OBJECTIVE

Preapproval randomized controlled trials of antiepileptic drugs provide data in limited patient groups. We assessed the side effect and seizure reduction profile of tiagabine (TGB) in typical clinical practice.

METHODS

Investigators recorded adverse effect (AE), seizure, and assessment-of-benefit data prospectively in sequential patients treated open label with TGB.

RESULTS

Two hundred ninety-two patients (39 children) were enrolled to be treated long term with TGB. Seizure types were focal-onset (86%), generalized-onset (12%), both focal- and generalized-onset (0.3%), and multiple associated with Lennox-Gastaut Syndrome (2%). Two hundred thirty-one received at least one dose of TGB (median = 28 mg/day) and had follow-up seizure or AE data reported. Common AEs were fatigue, dizziness, psychomotor slowing, ataxia, gastrointestinal upset, weight change, insomnia, and "others" (mostly behavioral). Serious AEs occurred in 19 patients: behavioral effects (n = 12), status epilepticus (n = 3), others (n = 3), and sudden unexplained death (n = 1). No patients experienced suicidal ideation/behavior, rash, nephrolithiasis, or organ failure. Seizure outcomes were seizure freedom (5%), ≥75% reduction (12%), ≥50% reduction (23%), and increased number of seizures (17%), or new seizure type (1%).

CONCLUSIONS

Behavioral AEs occurred in a larger proportion of patients compared to those reported in TGB preapproval randomized controlled trials. A moderate percentage of patients had a meaningful reduction in seizure frequency. In clinical practice, TGB remains a useful antiepileptic drug.

The cognitive impact of antiepileptic drugs

Effective treatment of epilepsy depends on medication compliance across a lifetime, and studies indicate that drug tolerability is a significant limiting factor in medication maintenance. Available antiepileptic drugs (AEDs) have the potential to exert detrimental effects on cognitive function and therefore compromise patient wellbeing. On the other hand, some agents may serve to enhance cognitive function. In this review paper, we highlight the range of effects on cognition linked to a variety of newer and older AEDs, encompassing key alterations in both specific executive abilities and broader neuropsychological functions. Importantly, the data reviewed suggest that the effects exerted by an AED could vary depending on both patient characteristics and drug-related variables. However, there are considerable difficulties in evaluating the available evidence. Many studies have failed to investigate the influence of patient and treatment variables on cognitive functioning. Other difficulties include variation across studies in relation to design, treatment group and assessment tools, poor reporting of methodology and poor specification of the cognitive abilities assessed. Focused and rigorous experimental designs including a range of cognitive measures assessing more precisely defined abilities are needed to fill the gaps in our knowledge and follow up reported patterns in the literature. Longitudinal studies are needed to improve our understanding of the influence of factors such as age, tolerance and the stability of cognitive effects. Future trials comparing the effects of commonly prescribed agents across patient subgroups will offer critical insight into the role of patient characteristics in determining the cognitive impact of particular AEDs.

The impact of epilepsy on children and adult patients' lives: development of a conceptual model from qualitative literature

AIM

This study aimed to develop a conceptual model of the impact of partial onset or generalized epilepsy on children and adults in order to guide the identification of endpoints that capture patient perspectives in new treatment trials.

METHODS

A systematic literature search was conducted in Embase and Medline to identify qualitative research reporting the impact of epilepsy on child and adult patients' lives. The search identified 20 publications describing 18 qualitative studies. Qualitative results were extracted from these publications into structured summary tables separately for impact on children and adults.

RESULTS

Results tables were reviewed by two qualitative researchers who identified 23 concepts/areas of impact. Concepts were largely universal between child and adult studies, although concept content did vary between age-groups, for example child relationship concerns were focused on developing friendships and problematic family relationships. For adults the concerns were problematic relationships with spouse or partner and fulfilling the family roles. Concepts influenced directly by epilepsy were cognitive, physical and seizure effects, other concepts such as future hopes, burden and self-esteem were influenced more indirectly by impact on other concepts. The 23 concepts were linked to form a conceptual model of the impact of epilepsy for patients guided by qualitative results reported by studies.

CONCLUSION

The conceptual model suggests potential areas of patients' lives that may be enhanced by effective treatment and allows for concepts of concern to both children and adults to be identified and explored as potential endpoints in trials of new epilepsy treatments.

Zonisamide: Physician and patient experiences

This study evaluates information regarding physician and patient experiences with zonisamide obtained from the early access and support for epilepsy (EASE) program. Both physicians and patients completed initiation questionnaires regarding seizure history and antiepileptic drug (AED) use. Physicians were advised to initiate zonisamide at 100 mg/day and titrate either to a clinical response or a maximum dosage of 600 mg/day. After > or = 2 months of zonisamide therapy, physicians and patients were asked to complete follow-up questionnaires that included questions regarding seizure frequency, seizure severity, and quality of life. Initiation questionnaires and follow-up questionnaires were submitted by 80 physicians for 163 patients. According to these data, seizure control, functional status, and other symptoms of epilepsy were improved in 57.4% (93/162), 37.1% (59/159), and 30.6% (48/157) of patients, respectively. Physicians intended to continue zonisamide therapy in 77.4% (123/159) of patients. Ninety-six patients submitted both initiation and follow-up questionnaires. Seizure control, seizure severity, and quality of life were improved in 53.6% (45/84), 58.8% (50/85), and 62.1% (54/87) of patients, respectively. These patients, most of whom were refractory to other AEDs, generally had positive experiences with zonisamide.

Assessment of adverse events and quality of life in epilepsy: design of a new community-based trial

Improving health-related quality of life (HRQOL) has become recognized as an essential component of treating patients with epilepsy. In recent years, several rating scales have been developed that focus on both common adverse effects and various aspects of HRQOL that are more relevant to this patient population. Increasingly, such assessments are being incorporated into clinical trials, as it becomes clear that improvements in overall quality of life are an important feature of drug therapy. Here we present the design of a large, community-based trial evaluating the effects of switching from immediate-release carbamazepine to twice-daily, beaded, extended-release carbamazepine (Carbatrol). As this trial involves switching formulations of the same compound, we expect to find only small differences in efficacy but significant differences in tolerability and quality-of-life measures. To identify appropriate instruments that could measure these factors, here we review several epilepsy-specific scales used to monitor adverse events and HRQOL and discuss their potential utility in the context of the proposed trial.

New antiepileptic drugs: comparative studies of efficacy and cognition

Over the past 10 years, the Food and Drug Administration has approved eight prophylactic antiepileptic drugs (AEDs). Although the goal of universal seizure control without side effects has not been reached, the tolerability of medications has improved. This paper reviews the AEDs introduced since 1993 and tries to objectively present comparative data obtained in double-blind studies.