Seizure clusters: characteristics and treatment

Evaluation and clinical characteristics of anxiety, depression, and sleep quality among adult patients with seizure clusters

OBJECTIVE

This study aims to examine the clinical characteristics among seizure clusters (SCs) in adult patients with epilepsy, measure anxiety and depression symptoms, sleep quality and analyze risk factors related to these conditions while assessing their social burden.

METHODS

The Generalized Anxiety Disorder-7 (GAD-7), the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E), the Pittsburgh Sleep Quality Index (PSQI), and the Social Support Rating Scale (SSRS) were among the structured questionnaires utilized in Sichuan Provincial People's Hospital. Multivariate logistic regression analysis was conducted on the related differential indicators.

RESULTS

A total of 330 adult patients with epilepsy were included. Statistically significant differences (p < 0.05) were found between the patients with SCs and without groups in terms of age at first onset, etiology, semiology distribution, imaging and EEG results, therapy, and prognosis. SC patients had significantly higher GAD-7, NDDI-E, and PSQI average total scores than in the Non-Seizure Cluster (NSC) group. (p < 0.001), and the distribution of related factors varying by age and daily seizure frequency. Patients with SCs had shown lower objective support, including material support, social networks, and group relationships than the control group SIGNIFICANCE: SCs are a type of clinical emergency. Patients with SCs are more susceptible to anxiety, depression, poor sleep quality and social burden, requiring proactive intervention and mental health management. This study is registered with the Chinese Clinical Trials Registry (identifier: ChiCTR2400088157).

Inductive reasoning with large language models: A simulated randomized controlled trial for epilepsy

INTRODUCTION

To investigate the potential of using artificial intelligence (AI), specifically large language models (LLMs), for synthesizing information in a simulated randomized clinical trial (RCT) for an anti-seizure medication, cenobamate, demonstrating the feasibility of inductive reasoning via medical chart review.

METHODS

An LLM-generated simulated RCT was conducted, featuring a placebo arm and a full-strength drug arm with a cohort of 240 patients divided 1:1. Seizure counts were simulated using a realistic seizure diary simulator. The study utilized LLMs to generate clinical notes with four neurologist writing styles and random extraneous details. A secondary LLM pipeline synthesized data from these notes. The efficacy and safety of cenobamate in seizure control were evaluated by both an LLM-based pipeline and a human reader.

RESULTS

The AI analysis closely mirrored human analysis, demonstrating the drug's efficacy with marginal differences (<3 %) in identifying both drug efficacy and reported symptoms. The AI successfully identified the number of seizures, symptom reports, and treatment efficacy, with statistical analysis comparing the 50 %-responder rate and median percentage change between the placebo and drug arms, as well as side effect rates in each arm.

DISCUSSION

This study highlights the potential of AI to accurately analyze noisy clinical notes to inductively produce clinical knowledge. Here, treatment effect sizes and symptom frequencies derived from unstructured simulated notes were inferred despite many distractors. The findings emphasize the relevance of AI in future clinical research, offering a scalable and efficient alternative to traditional labor-intensive data mining.

Clinical characteristics, etiology, and treatment of young adult-onset epilepsy: A 24-year retrospective study

OBJECTIVE

To analyze the clinical characteristics, etiology, drug treatment, and related factors of patients with young adult-onset epilepsy.

METHODS

The study included patients with epilepsy aged between 18 and 44 years and aimed to analyze the clinical characteristics of epilepsy in young people and their response to antiseizure medication (ASM) over a 24-year period (February 1999 and March 2023).

RESULTS

A total of 4227 patients experienced epilepsy onset between 18 and 44 years of age. The median age of onset was 26 years (interquartile range [IQR]: 21-33), and the median duration from the first seizure to starting treatment was 3 months (IQR: 1.0-6.0). Structural etiology was the most common cause of epilepsy, accounting for 43.2% (1827/4227) of cases, of which head trauma and a history of craniotomy accounted for 64.9% (1186/1827). However, these two causes did not necessarily result in prompt medication or poor epilepsy control. Co-morbid cognitive decline was more prevalent than headache and anxiety/depression. Multifactorial regression analysis showed that the factors associated with poor seizure control included longer seizure duration (odds ratio [OR] 1.85; 95% confidence interval [CI] 1.58-2.16; p < 0.001), electroencephalography (EEG) epileptic discharge (OR 1.37; 95% CI 1.17-1.67; p < 0.001), focal seizure (OR 1.69; 95% CI 1.38-2.07; p < 0.001), and seizure clusters (OR 3.35; 95% CI 2.70-4.15; p < 0.001). Initiating treatment after two seizures (OR, 1.18; 95% CI 0.98-1.15; p = .08) or 6 months after the first seizure (OR 0.84; 95% CI 0.67-1.03; p = .09) did not worsen effectiveness.

SIGNIFICANCE

Young adult-onset epilepsy was frequently caused by head trauma or craniotomies. Co-morbid cognitive decline was more prevalent than headache and anxiety/depression. The median time from the first seizure to follow-up treatment was 3 months (IQR: 1.0-6.0). Initiating treatment after two seizures did not necessarily indicate poor drug effectiveness.

PLAIN LANGUAGE SUMMARY

In this article, we observed that young adult-onset epilepsy was mainly caused by head trauma and craniotomy; co-morbid cognitive decline was more common. The median duration from first seizure to initiation of treatment for young-onset epilepsy was 3 months, and more than one-third of patients experienced more than two seizures prior to treatment, but this factor had no effect on the drug effectiveness.

Benzodiazepine rescue medication administration for seizure clusters: Real-world retrospective outcomes

OBJECTIVE

Benzodiazepine rescue medications are established as therapy for acute termination of seizure clusters. A post-hoc analysis of a clinical trial of seizure cluster treatment with diazepam nasal spray found a potential longer-term impact over a year of treatment. In this retrospective analysis, we tested the hypothesis that benzodiazepine-treated seizure clusters are associated with prolonged time to the next seizure cluster compared with untreated seizure clusters in a patient-reported real-world database.

METHODS

We analyzed data on self-reported seizures and benzodiazepine rescue medication administration in the Seizure Tracker™ database between 2007 and 2022. Kaplan-Meier analysis was used to compare treated vs untreated seizure clusters with respect to time to start of the next seizure cluster or immediate-use medication administration. Mixed-effects analysis was used to compare the number of seizures per cluster for treated and untreated seizure clusters. Robustness of findings was evaluated across three operational seizure-cluster definitions: ≥2 seizures in 4 hours as primary analysis and in 6 and 24 hours as sensitivity analyses.

RESULTS

A total of 10 889 benzodiazepine immediate-use medication administrations (n = 220 patients) met inclusion criteria. Benzodiazepine rescue administrations were followed by longer time to the next seizure cluster or rescue administration, compared with untreated seizure clusters, corresponding to a median of 4.9 days following treated seizure clusters and a median of 0.8 days following untreated seizure clusters. This prolongation was driven by a minority of patients (accounting for 45.9% of seizure clusters in the sample) and patients were more likely to be women. The number of seizures per cluster was lower when treatment was administered earlier in the seizure cluster.

SIGNIFICANCE

These retrospective real-world data suggest that the effect of benzodiazepines on termination of seizure clusters may be more pronounced when administration occurs earlier after onset, and support a hypothesis of a possible longer-term effect of benzodiazepines beyond immediate-use acute seizure termination.

Immediate Treatment of Seizure Clusters: A Conceptual Roadmap to Expedited Seizure Management

Some patients with epilepsy continue to have seizures despite daily treatment with antiseizure medications. This includes seizure clusters (also known as acute repetitive seizures), which are an increase in seizure frequency that is different from the usual seizure pattern for that patient. In the literature, the term "rescue" is used for pharmacologic treatment for seizure clusters, but clarity regarding timing or whether a caregiver or patient should wait until a moment of life-threatening urgency before administering the medication is lacking. Additionally, the concept of waiting 5 minutes to identify and initiate treatment of status epilepticus has been carried over to the treatment of seizure clusters, as well as the idea of waiting owing to safety concerns, without reevaluation in the context of the reported safety profiles for currently available as-needed therapies when administered as prescribed. Delaying treatment of seizure clusters may have negative outcomes, including injury, emergency room use, hospitalization, and progression to status epilepticus. Additionally, increased time for administration of benzodiazepines, the cornerstone therapies for seizure clusters, may lower the potency and effectiveness once administration takes place, because of physiologic changes. Thus, clarifying the importance of timing in the treatment terminology may be of benefit in the acute context. The term "immediate-use seizure medication" (ISM), meaning treatment that is administered as quickly as possible once a seizure cluster is recognized, may help to clarify the timing of as-needed treatment. This review examines the recognition and definitions of seizure clusters, the physiologic rationale for ISM for seizure clusters, and the effectiveness and safety of early treatment. Remaining knowledge gaps are also discussed. The findings of this review suggest that it may be time to revisit the terminology of "rescue", which implies waiting to administer treatment for seizure clusters, as doing so is not supported by pathophysiologic, effectiveness, or safety data.

Real-world epilepsy monitoring with ultra long-term subcutaneous EEG: a 15-month prospective study

Objective

Novel subcutaneous electroencephalography (sqEEG) systems enable prolonged, near-continuous cerebral monitoring in real-world conditions. Nevertheless, the feasibility, acceptability and overall clinical utility of these systems remains unclear. We report on the longest observational study using ultra long-term sqEEG to date.

Methods

We conducted a 15-month prospective, observational study including ten adult people with treatment-resistant epilepsy. After device implantation, patients were asked to record sqEEG, to use an electronic seizure diary and to complete acceptability and usability questionnaires. sqEEG seizures were annotated visually, aided by automated detection. Seizure clustering was assessed via Fano Factor analysis and seizure periodicity at multiple timescales was investigated through circular statistics.

Results

Over a median duration of 438 days, ten patients recorded a median 18.8 hours/day, totalling 71,984 hours of real-world sqEEG data. Adherence and acceptability remained high throughout the study. While 754 sqEEG seizures were recorded across patients, over half (52%) of these were not reported in the patient diary. Of the 140 (27%) diary reports not associated with an identifiable sqEEG seizure, the majority (68%) were reported as seizures with preserved awareness. The sqEEG to diary F1 agreement score was highly variable, ranging from 0.06 to 0.97. Patient-specific patterns of seizure clustering and seizure periodicity were observed at multiple (circadian and multidien) timescales.

Interpretation

We demonstrate feasibility and high acceptability of ultra long-term (months-years) sqEEG monitoring. These systems help provide real-world, more objective seizure counting compared to patient diaries. It is possible to monitor individual temporal fluctuations of seizure occurrence, including seizure cycles.

Statistical characteristics of large-scale objective tonic-clonic seizure records from medical smartwatches used in daily life

OBJECTIVE

This study aimed to assess whether population-level patterns in seizure occurrence previously observed in self-reported diaries, medical records, and electroencephalographic recordings were also present in tonic-clonic seizure (TCS) diaries produced via the combined input of a US Food and Drug Administration-cleared wristband with an artificial intelligence detection algorithm and patient self-reports. We also investigated the characteristics of patient interactions with wearable seizure alerts.

METHODS

We analyzed wristband data from patients with TCSs who had at least three reported TCSs over a minimum of 90 days. We quantified TCS frequency and cycles, and the relationship between the mean and variability of monthly TCS counts. We also assessed interaction metrics such as false alarm dismissal and seizure confirmation rates.

RESULTS

Applying strict criteria for usable data, we reviewed 137 490 TCSs from 3012 patients, with a median length of TCS alert records of 445 days (range = 90-1806). Analyses showed consistency between prior diary studies and the present data concerning (1) the distribution of monthly TCS frequency (median = 3.1, range = .08-26); (2) the linear relationship (slope = .79, R2 = .83) between the logarithm of the mean and the logarithm of the SD of monthly TCS frequency (L-relationship); and (iii) the prevalence of multiple coexisting seizure cycles, including circadian (84.0%), weekly (24.6%), and long-term cycles (31.1%).

SIGNIFICANCE

Key population-level patterns in seizure occurrence are recapitulated in wrist-worn device recordings, supporting their validity for tracking TCS burden. Compared to other approaches, wearables can provide noninvasive, objective, long-term data, revealing cycles in seizure risk. However, improved patient engagement with wristband alerts and further validation of detection accuracy in ambulatory settings are needed. Together, these findings suggest that data from smart wristbands may be used to derive features of TCS records and, ultimately, facilitate remote monitoring and the development of personalized forecasting tools for TCS management. Our findings may not generalize to other types of seizures.

Increasing adult-born neurons protects mice from epilepsy

Neurogenesis occurs in the adult brain in the hippocampal dentate gyrus, an area that contains neurons which are vulnerable to insults and injury, such as severe seizures. Previous studies showed that increasing adult neurogenesis reduced neuronal damage after these seizures. Because the damage typically is followed by chronic life-long seizures (epilepsy), we asked if increasing adult-born neurons would prevent epilepsy. Adult-born neurons were selectively increased by deleting the pro-apoptotic gene Bax from Nestin-expressing progenitors. Tamoxifen was administered at 6 weeks of age to conditionally delete Bax in Nestin-CreERT2Baxfl/fl mice. Six weeks after tamoxifen administration, severe seizures (status epilepticus; SE) were induced by injection of the convulsant pilocarpine. After mice developed epilepsy, seizure frequency was quantified for 3 weeks. Mice with increased adult-born neurons exhibited fewer chronic seizures. Postictal depression was reduced also. These results were primarily in female mice, possibly because they were more affected by Bax deletion than males, consistent with sex differences in Bax. The female mice with enhanced adult-born neurons also showed less neuronal loss of hilar mossy cells and hilar somatostatin-expressing neurons than wild-type females or males, which is notable because loss of these two hilar cell types is implicated in epileptogenesis. The results suggest that selective Bax deletion to increase adult-born neurons can reduce experimental epilepsy, and the effect shows a striking sex difference. The results are surprising in light of past studies showing that suppressing adult-born neurons can also reduce chronic seizures.

Characteristics and treatment of midlife-onset epilepsy: A 24-year single-center, retrospective study

OBJECTIVE

This study aimed to analyze the clinical characteristics, etiology, and treatment of midlife-onset epilepsy in a real-world setting at a single center in China.

METHODS

The clinical data of patients who attended the epilepsy clinic of the Department of Neurology, First Medical Center of Chinese PLA General Hospital from February 1999 to March 2023 were retrospectively analyzed. The clinical characteristics, etiology, and risk factors for midlife-onset epilepsy over the past 24 years were analyzed.

RESULTS

Of the 969 patients with onset at 45-64 years of age, 914 were diagnosed with epilepsy with at least two unprovoked seizures 24 h apart. Of those, 99.7% (911) were of focal origin. The median duration from the initial seizure to follow-up treatment was 2 months (interquartile range [IQR]: 1.0-6.0 months). Before commencing treatment, 30.2% (207/683) of patients experienced more than two seizures. A structural etiology was found in 66.3% (606/914) of patients. Cerebrovascular disease (CVD) and traumatic brain injury (TBI) accounted for 19.9% (182/914) and 16.6% (152/914) of the cases, respectively. Logistic regression analysis showed that patients with abnormal imaging (odds ratio [OR] 2.04; 95% confidence interval [CI] 1.25-3.32; p = .004), focal seizures (OR 2.98; 95%CI 1.82-4.87; p < .001), and seizure clusters (OR 2.40; 95%CI 1.21-4.73; p = .01) had poor drug responses. Treatment outcomes were generally better in patients with epilepsy after CVD (OR .49; 95%CI .28-.85; p = .01). Treatment initiation after two seizures (OR .70; 95%CI .42-1.15; p = .16) or 6 months after the first seizure (OR 1.17; 95%CI .66-2.09; p = .58) did not result in poor drug effectiveness.

SIGNIFICANCE

Midlife-onset epilepsy is typically of focal etiology, with CVD being the most common cause, and tends to respond well to medication. The median duration from the initial seizure to follow-up treatment was 2 months. Over 30% of patients experienced more than two seizures before commencing treatment, but this did not affect subsequent outcomes.

Increasing adult-born neurons protects mice from epilepsy

Neurogenesis occurs in the adult brain in the hippocampal dentate gyrus, an area that contains neurons which are vulnerable to insults and injury, such as severe seizures. Previous studies showed that increasing adult neurogenesis reduced neuronal damage after these seizures. Because the damage typically is followed by chronic life-long seizures (epilepsy), we asked if increasing adult-born neurons would prevent epilepsy. Adult-born neurons were selectively increased by deleting the pro-apoptotic gene Bax from Nestin-expressing progenitors. Tamoxifen was administered at 6 weeks of age to conditionally delete Bax in Nestin-CreERT2 Bax fl/fl mice. Six weeks after tamoxifen administration, severe seizures (status epilepticus; SE) were induced by injection of the convulsant pilocarpine. After mice developed epilepsy, seizure frequency was quantified for 3 weeks. Mice with increased adult-born neurons exhibited fewer chronic seizures. Postictal depression was reduced also. These results were primarily in female mice, possibly because they were the more affected by Bax deletion than males, consistent with sex differences in Bax. The female mice with enhanced adult-born neurons also showed less neuronal loss of hilar mossy cells and hilar somatostatin-expressing neurons than wild type females or males, which is notable because these two hilar cell types are implicated in epileptogenesis. The results suggest that selective Bax deletion to increase adult-born neurons can reduce experimental epilepsy, and the effect shows a striking sex difference. The results are surprising in light of past studies showing that suppressing adult-born neurons can also reduce chronic seizures.

Intravenous Lacosamide Therapy for Pediatric Patients With Cluster Seizures

BACKGROUND

Few studies have investigated intravenous lacosamide use to treat cluster seizures in pediatric patients. Therefore, we aimed to investigate the efficacy and safety of intravenous lacosamide therapy in pediatric patients with cluster seizures.

METHODS

We retrospectively evaluated the efficacy and safety of intravenous lacosamide therapy in 25 pediatric patients with cluster seizures at Saitama Children's Medical Center between March 2019 and June 2023. Cluster seizures were defined as a single seizure of less than five minutes duration, repeated three or more times within 12 hours, with recovery of consciousness between seizures. Response was defined as seizure freedom for at least 12 hours after lacosamide infusion.

RESULTS

The median age at onset of epilepsy was 1.5 (0.0 to 9.8) years. The median seizure frequency was 5 (3 to 20) times per 12 hours. The etiologies were remote (n = 17), acute (n = 4), and progressive (n = 4). The median age at which intravenous lacosamide therapy was administered was 4.2 (0.0 to 11.3) years. The median lacosamide dose was 2.6 (1.3 to 5.2) mg/kg. In total, 12 of 25 patients (48.0%) responded. Among patients treated with intravenous lacosamide as first-line therapy, nine of 17 (52.9%) had complete seizure remission. The frequency of complete seizure remission in patients with remote etiologies was 58.8% (10 of 17); among them, seven of 12 (58.3%) patients with structural abnormalities showed complete seizure remission. No adverse events were observed.

CONCLUSIONS

Intravenous lacosamide therapy is a potentially useful treatment option for cluster seizures in pediatric patients.

Seizure clusters, treatment patterns, and healthcare resource utilization in patients with epilepsy: A Wisconsin-based claims analysis

BACKGROUND

Seizure clusters are underresearched and associated with adverse outcomes in patients with epilepsy. This study was a noninterventional, retrospective claims-based analysis using the Wisconsin Health Information Organization (WHIO) All-Payer Claims Database to characterize the epilepsy population in Wisconsin, with a focus on prevalence, treatment patterns, and healthcare resource utilization (HCRU) in patients with seizure clusters prior to the introduction of nasal spray rescue medications. This timeframe allows characterization of a historical baseline for future comparisons with newer treatments.

METHODS

Four cohorts were defined: (1) all-epilepsy (all patients with epilepsy); and subcohorts of: (2) patients receiving a monotherapy antiseizure medication (ASM); (3) patients receiving ASM polytherapy; and (4) patients treated for seizure clusters (ie, those taking rescue medications and ≥ 1 ASM). Primary outcomes were HCRU over a 12-month follow-up period, which were descriptively analyzed.

RESULTS

Between 2017 and 2019, 16,384 patients were included in the all-epilepsy cohort; 11,688 (71.3 %) were on monotherapy, 3,849 (23.5 %) were on polytherapy, and 526 (3.2 %) were treated for seizure clusters. Twelve-month retentions to the ASM treatments were 46.7 % (7,895/16,904) in the all-epilepsy cohort, and 40.0 % (4,679/11,688) and 40.1 % (1,544/3,849) in the monotherapy and polytherapy subcohorts, respectively. Rescue medication prescriptions were obtained 1,029 times by the 526 patients in the treated seizure cluster subcohort, with infrequent refill rates (mean 1.6-1.9 times/year). A higher proportion of patients in the treated seizure cluster subcohort had epilepsy-related outpatient visits (89.7 %), other visits (71.3 %), and hospitalizations (25.3 %) than patients in the monotherapy (72.2 %, 50.2 %, 19.3 %, respectively) and polytherapy (83.3 %, 63.3 %, 22.8 %, respectively) subcohorts. Mean (standard deviation) all-cause ($114,717 [$231,667]) and epilepsy-related ($76,134 [$204,930]) costs over 12 months were higher in the treated seizure cluster subcohort than the monotherapy ($89,324 [$220,181] and $30,745 [$145,977], respectively) and polytherapy ($101,506 [$152,931] and $49,383 [$96,285], respectively) subcohorts.

CONCLUSIONS

Patients treated for seizure clusters incurred higher all-cause and epilepsy-related costs and epilepsy-related HCRU than other subcohorts and had infrequent rescue medication refills. The findings of this analysis highlight the need for appropriate treatment for those patients with epilepsy experiencing seizure clusters. The effect of newer rescue medications to alter these findings will be explored in a follow-up study. Regardless, specialist providers with expertise in treating refractory epilepsy and seizure cluster patients may help to reduce the burden of seizure clusters.

How accurate do self-reported seizures need to be for effective medication management in epilepsy?

Studies suggest that self-reported seizure diaries suffer from 50% under-reporting on average. It is unknown to what extent this impacts medication management. This study used simulation to predict the seizure outcomes of a large heterogeneous clinic population treated with a standardized algorithm based on self-reported seizures. Using CHOCOLATES, a state-of-the-art realistic seizure diary simulator, 100 000 patients were simulated over 10 years. A standard algorithm for medication management was employed at 3 month intervals for all patients. The impact on true seizure rates, expected seizure rates, and time-to-steady-dose were computed for self-reporting sensitivities 0%-100%. Time-to-steady-dose and medication use mostly did not depend on sensitivity. True seizure rate decreased minimally with increasing self-reporting in a non-linear fashion, with the largest decreases at low sensitivity rates (0%-10%). This study suggests that an extremely wide range of sensitivity will have similar seizure outcomes when patients are clinically treated using an algorithm similar to the one presented. Conversely, patients with sensitivity ≤10% would be expected to benefit (via lower seizure rates) from objective devices that provide even small improvements in seizure sensitivity.

Anticipatory anxiety of seizures in epilepsy: A common, complex, and underrecognized phenomenon?

The diagnosis of epilepsy is associated with loss of predictability, which invariably results in the fear of when and if future seizures will occur. For a subset of patients with epilepsy (PWE), there may be a pathological persistent fear of seizure occurrence, resulting in limitations to daily activities through avoidant behaviors. Paradoxically, the research of anticipatory anxiety of seizures (AAS; also referred to as seizure phobia) has been practically nonexistent and, not surprisingly, this condition remains underrecognized by clinicians. The available data are derived from three small case series of patients followed in tertiary epilepsy centers. In this study, we review the available data on the reported clinical manifestations of AAS in PWE, and of the potential role of variables associated with it, such as personal and family psychosocial and psychiatric history and epilepsy-related variables. In addition, we review the need for the creation of screening tools to identify patients at risk of AAS and discuss potential treatment strategies, which could be considered as part of the comprehensive management for PWE.

Prospective validation of a seizure diary forecasting falls short

OBJECTIVE

Recently, a deep learning artificial intelligence (AI) model forecasted seizure risk using retrospective seizure diaries with higher accuracy than random forecasts. The present study sought to prospectively evaluate the same algorithm.

METHODS

We recruited a prospective cohort of 46 people with epilepsy; 25 completed sufficient data entry for analysis (median = 5 months). We used the same AI method as in our prior study. Group-level and individual-level Brier Skill Scores (BSSs) compared random forecasts and simple moving average forecasts to the AI.

RESULTS

The AI had an area under the receiver operating characteristic curve of .82. At the group level, the AI outperformed random forecasting (BSS = .53). At the individual level, AI outperformed random in 28% of cases. At the group and individual level, the moving average outperformed the AI. If pre-enrollment (nonverified) diaries (with presumed underreporting) were included, the AI significantly outperformed both comparators. Surveys showed most did not mind poor-quality LOW-RISK or HIGH-RISK forecasts, yet 91% wanted access to these forecasts.

SIGNIFICANCE

The previously developed AI forecasting tool did not outperform a very simple moving average forecasting in this prospective cohort, suggesting that the AI model should be replaced.

Diazepam nasal spray administration is effective to control seizure clusters irrespective of time of day

Introduction

Neurologic circadian influences, including sleep/wake transitions, processes (e.g., hormonal variation), and behavioral patterns (e.g., consumption of food and oral medications), may affect seizure patterns. Specific circadian patterns of seizures have been reported depending on type, onset location, and severity; however, data on patterns for patients with seizure clusters and effectiveness of rescue therapy by time of day are limited.

Methods

We conducted post hoc analyses using patient diary data from the phase 3 safety study of diazepam nasal spray, which is indicated for acute treatment of seizure clusters in patients with epilepsy aged ≥6 years. Patients were administered age- and weight-based doses; second doses could be administered if needed to control a seizure cluster. We assessed clock timing of seizure-cluster onset along with second-dose use as a proxy for effectiveness. Treatment-emergent adverse events were recorded.

Results

Seizure-cluster onset was observed to be generally highest during mornings and late evenings and lowest in the early evening and middle of the night. Second-dose use was not consistently associated with a specific time of day. The safety profile was consistent with that expected from previous studies of diazepam nasal spray.

Conclusion

These results suggest that diazepam nasal spray can be effectively administered at any time of day.

Neurological function and drug-refractory epilepsy in Sturge-Weber syndrome children: a retrospective analysis

Epilepsy in Sturge-Weber syndrome (SWS) is common, but drug-refractory epilepsy (DRE) in SWS has rarely been studied in children. We investigated the characteristics of epilepsy and risk factors for DRE in children with SWS. A retrospective study was conducted to analyze the clinical characteristics of children with SWS with epilepsy in our hospital from January 2013 to October 2022. Univariate and multivariate logistic analyses were performed to investigate the factors influencing DRE in children with SWS. A total of 35 SWS children with epilepsy were included (51% male; mean age of presentation 3.6 ± 0.5 years), 71% of children with SWS had their first seizure within the first year of life, and the most common type of seizure was focal seizure (77%). Eleven (31%) patients developed DRE. The median age of onset for the first seizure was 1.0 years and all these cases were of SWS type I. Multivariate logistic analysis revealed that stroke-like episodes and seizure clusters were risk factors for DRE in SWS children. A poor neurological function group was observed in twenty-five children with SWS. Status epilepticus was a risk factor that affected the neurological function of SWS children with epilepsy.  Conclusion: The study explored the epileptic features of children with SWS. The results revealed that stroke-like episodes and seizure clusters are risk factors for DRE in children with SWS. The occurrence of status epilepticus impacts the neurological function of SWS children with epilepsy. Thus, long-term follow-up is necessary to monitor outcomes. What is Known: • Sturge-Weber syndrome (SWS) is a rare neurocutaneous disorder, over 75% of children with SWS experience seizures, and 30-57% develop drug-refractory epilepsy (DRE), which leads to a poor outcome. • Drug-refractory epilepsy in SWS has been rarely studied in children, and the risk factors associated with DRE are unclear. What is New: • Clinical features of SWS children with drug-refractory epilepsy. • In SWS, stroke-like episodes and seizure clusters are risk factors of DRE, the occurrence of status epilepticus impacts the neurological function.

Analysis of seizure-cluster circadian periodicity from a long-term, open-label safety study of diazepam nasal spray

OBJECTIVE

Seizure clusters require prompt medical treatment to minimize possible progression to status epilepticus, increased health care use, and disruptions to daily life. Isolated seizures may exhibit cyclical patterns, including circadian and longer rhythms. However, little is known about the cyclical patterns in seizure clusters. This post hoc analysis of data from a long-term, phase 3, open-label, repeat-dose safety study of diazepam nasal spray modeled the periodicity of treated seizure clusters.

METHODS

Mixed-effects cosinor analysis evaluated circadian rhythmicity, and single component cosinors using 12 and 24 h were used to calculate cosinor parameters (e.g., midline statistic of rhythm, wave ampitude, and acrophase [peak]). Analysis was completed for the full cohort and a consistent cohort of participants with two or more seizure clusters in each of four, 3-month periods. The influence of epilepsy type on cosinor parameters was also analyzed.

RESULTS

Seizure-cluster events plotted across 24 h showed a bimodal distribution with acrophases (peaks) at ~06:30 and ~18:30. A 12-h plot showed a single peak at ~06:30. Cosinor analyses of the full and consistent cohort aligned, with acrophases for both models predicting peak seizure activity at ~23:30 on a 24-h scale and ~07:30 on a 12-h scale. The consistent cohort was associated with increases in baseline and peak seizure-cluster activity. Analysis by epilepsy type identified distinct trends. Seizure clusters in the focal epilepsy group peaked in the evening (acrophase 19:19), whereas events in the generalized epilepsy group peaked in the morning (acrophase 04:46). Together they compose the bimodal clustering observed over 24 h.

SIGNIFICANCE

This analysis of seizure clusters treated with diazepam nasal spray demonstrated that seizure clusters occur cyclically in 12- and 24-h time frames similar to that reported with isolated seizures. Further elucidation of these patterns may provide important information for patient care, ranging from improved patient-centered outcomes to seizure-cluster prediction.

Minimum clinical utility standards for wearable seizure detectors: A simulation study

OBJECTIVE

Epilepsy management employs self-reported seizure diaries, despite evidence of seizure underreporting. Wearable and implantable seizure detection devices are now becoming more widely available. There are no clear guidelines about what levels of accuracy are sufficient. This study aimed to simulate clinical use cases and identify the necessary level of accuracy for each.

METHODS

Using a realistic seizure simulator (CHOCOLATES), a ground truth was produced, which was then sampled to generate signals from simulated seizure detectors of various capabilities. Five use cases were evaluated: (1) randomized clinical trials (RCTs), (2) medication adjustment in clinic, (3) injury prevention, (4) sudden unexpected death in epilepsy (SUDEP) prevention, and (5) treatment of seizure clusters. We considered sensitivity (0%-100%), false alarm rate (FAR; 0-2/day), and device type (external wearable vs. implant) in each scenario.

RESULTS

The RCT case was efficient for a wide range of wearable parameters, though implantable devices were preferred. Lower accuracy wearables resulted in subtle changes in the distribution of patients enrolled in RCTs, and therefore higher sensitivity and lower FAR values were preferred. In the clinic case, a wide range of sensitivity, FAR, and device type yielded similar results. For injury prevention, SUDEP prevention, and seizure cluster treatment, each scenario required high sensitivity and yet was minimally influenced by FAR.

SIGNIFICANCE

The choice of use case is paramount in determining acceptable accuracy levels for a wearable seizure detection device. We offer simulation results for determining and verifying utility for specific use case and specific wearable parameters.

Inductive reasoning with large language models: a simulated randomized controlled trial for epilepsy

Importance

The analysis of electronic medical records at scale to learn from clinical experience is currently very challenging. The integration of artificial intelligence (AI), specifically foundational large language models (LLMs), into an analysis pipeline may overcome some of the current limitations of modest input sizes, inaccuracies, biases, and incomplete knowledge bases.

Objective

To explore the effectiveness of using an LLM for generating realistic clinical data and other LLMs for summarizing and synthesizing information in a model system, simulating a randomized clinical trial (RCT) in epilepsy to demonstrate the potential of inductive reasoning via medical chart review.

Design

An LLM-generated simulated RCT based on a RCT for treatment with an antiseizure medication, cenobamate, including a placebo arm and a full-strength drug arm, evaluated by an LLM-based pipeline versus a human reader.

Setting

Simulation based on realistic seizure diaries, treatment effects, reported symptoms and clinical notes generated by LLMs with multiple different neurologist writing styles.

Participants

Simulated cohort of 240 patients, divided 1:1 into placebo and drug arms.

Intervention

Utilization of LLMs for the generation of clinical notes and for the synthesis of data from these notes, aiming to evaluate the efficacy and safety of cenobamate in seizure control either with a human evaluator or AI-pipeline.

Measures

The AI and human analysis focused on identifying the number of seizures, symptom reports, and treatment efficacy, with statistical analysis comparing the 50%-responder rate and median percentage change between the placebo and drug arms, as well as side effect rates in each arm.

Results

AI closely mirrored human analysis, demonstrating the drug's efficacy with marginal differences (<3%) in identifying both drug efficacy and reported symptoms.

Conclusions and Relevance

This study showcases the potential of LLMs accurately simulate and analyze clinical trials. Significantly, it highlights the ability of LLMs to reconstruct essential trial elements, identify treatment effects, and recognize reported symptoms, within a realistic clinical framework. The findings underscore the relevance of LLMs in future clinical research, offering a scalable, efficient alternative to traditional data mining methods without the need for specialized medical language training.

The impact of a history of status epilepticus for epilepsy surgery outcome

OBJECTIVE

Patients with focal drug resistant epilepsy are excellent candidates for epilepsy surgery. Status epilepticus (SE) and seizure clusters (SC), described in a subset of patients, have both been associated with extended epileptogenic cerebral networks within one or both hemispheres. In this retrospective study, we were interested to determine if a history of SE or SC is associated with a worse surgical outcome.

METHODS

Data of 244 patients operated between 2000 to 2018 were reviewed, with a follow-up of at least 2 years. Patients with a previous history of SE or SC were compared to operated patients without these conditions (control group, CG).

RESULTS

We identified 27 (11%) and 38 (15.5%) patients with history of SE or SC, respectively. No difference in post-operative outcome was found for SE and SC patients. Compared to the control group, patients with a history of SE were diagnosed and operated significantly at earlier age(p = 0.01), and after a shorter duration of the disease (p = 0.027), but with a similar age of onset.

SIGNIFICANCE

A history of SE or SC was not associated with a worse post-operative prognosis. Earlier referral of SE patients for surgery suggests a heightened awareness regarding serious complications of recurrent SE by the referring neurologist or neuropediatrician. While the danger of SE is evident, policies to underline the impact for SC or very frequent seizures might be an efficient approach to accelerate patient referral also for this patient group.

Benzodiazepines for the Treatment of Seizure Clusters

Patients with epilepsy may experience seizure clusters, which are described by the US Food and Drug Administration (FDA) as intermittent, stereotypic episodes of frequent seizure activity that are distinct from a patient's usual seizure pattern. Untreated seizure clusters may increase the risk for status epilepticus, as well as decrease quality of life and increase burden on patients and care partners. Benzodiazepine therapies are the mainstay for acute treatment of seizure clusters and are often administered by nonmedical care partners outside a healthcare facility. Three rescue therapies are currently FDA-approved for this indication, with diazepam rectal gel being the first in 1997, for patients aged ≥  2 years. Limitations of rectal administration (e.g., positioning and disrobing the patient, which may affect ease of use and social acceptability; interpatient variation in bioavailability) led to the investigation of the potential for nasal administration as an alternative. Midazolam nasal spray (MDS) was approved by the FDA in 2019 for patients aged ≥  12 years and diazepam nasal spray (DNS) in 2020 for patients aged ≥  6 years; these two intranasal therapies have differences in their formulations [e.g., organic solvents (MDS) vs. Intravail and vitamin E for absorption and solubility (DNS)], effectiveness (e.g., proportion of seizure clusters requiring only one dose), and safety profiles. In clinical studies, the proportion of seizure clusters for which only one dose of medication was used varied between the three approved rescue therapies with the highest single-dose rate for any time period for DNS; however, although studies for all three preparations enrolled patients with highly intractable epilepsy, inclusion and exclusion criteria varied, so the three cannot be directly compared. Treatments that have been used off-label for seizure clusters in the USA include midazolam for injection as an intranasal spray (indicated for sedation/anxiolysis/amnesia and anesthesia) and tablet forms of clonazepam (indicated for treatment for seizure disorders) and lorazepam (indicated for anxiety). In the European Union, buccal and intranasal midazolam are used for treating the indication of prolonged, acute convulsive seizures and rectal diazepam solution for the indication of epileptic and febrile convulsions; duration of effectiveness for these medications for the treatment of seizure clusters has not been established. This paper examines the literature context for understanding seizure clusters and their treatment and provides effectiveness, safety, and administration details for the three FDA-approved rescue therapies. Additionally, other medications that are used for rescue therapy in the USA and globally are discussed. Finally, the potential benefits of seizure action plans and candidates for their use are addressed. This paper is intended to provide details about the unique characteristics of rescue therapies for seizure clusters to help clarify appropriate treatment for individual patients.

Rapid Rescue Treatment with Diazepam Nasal Spray Leads to Faster Seizure Cluster Termination in Epilepsy: An Exploratory Post Hoc Cohort Analysis

INTRODUCTION

Although prompt treatment of status epilepticus is standard of care, the effect of timing of rescue therapy administration for seizure clusters in epilepsy remains unknown. Seizure clusters are a rare but clinically important condition, and benzodiazepines are the cornerstone rescue therapy for seizure clusters in epilepsy. We characterized temporal patterns from a large dataset of treated seizure clusters in the safety study of diazepam nasal spray.

METHODS

This post hoc analysis used timing data of treated seizure clusters recorded by care partners and patients in seizure diaries during a 1-year safety study. Data analysis used time from seizure start to administration of diazepam.

RESULTS

From 4466 observations, 3225 had data meeting criteria for analysis. Overall, median times from seizure start to dose administration, dose administration to seizure termination, and total seizure duration were 2, 3, and 7 min, respectively. In seizure clusters treated in < 5 min (median 1.0 min), median time from dose to seizure termination was 2.0 min, and median total seizure duration was 4.0 min. Among seizure clusters treated in ≥ 5 min (median 10.0 min), median time to seizure termination was 10.0 min, and median total seizure duration was 23.0 min. Previously published safety results reported that over a mean participation of 1.5 years, 82.2% of patients had ≥ 1 treatment-emergent adverse events (TEAEs) irrespective of relationship to treatment, including 30.7% with serious TEAEs; 18.4% had TEAEs deemed at least possibly related to the study drug, none of which were serious. There were no events of cardiorespiratory depression.

CONCLUSION

Echoing the importance of early use of benzodiazepines in status epilepticus, the findings from this exploratory analysis of patients with refractory epilepsy and frequent seizure clusters identify a potential benefit of early diazepam nasal spray treatment leading to faster seizure resolution within the seizure cluster. Trial Registration Information: ClinicalTrials.gov identifier NCT02721069 ( https://clinicaltrials.gov/ct2/show/NCT02721069 ).

Opportunities for Community Pharmacists to Counsel Patients With Epilepsy and Seizure Clusters to Overcome Barriers and Foster Appropriate Treatment

Some patients with epilepsy experience seizure clusters, which may be defined as 2 or more seizures occurring within 24 hours. Left untreated, seizure clusters increase the risk for physical injury and may progress to status epilepticus, irreversible neurologic injury, and death. Rescue therapy is based on benzodiazepine treatment. Prompt, appropriate use should be specified in patients' individualized seizure action plans. Most seizure clusters occur outside the hospital setting. The ideal rescue therapy allows for easy and quick administration by a nonmedical person, which may minimize the need for intervention by emergency medical personnel or transportation to the hospital. In the 2 decades before the approval of 2 intranasal benzodiazepines in 2019 and 2020, rectal diazepam was the only route of administration approved by the US Food and Drug Administration specifically for seizure clusters. Each of the approved intranasal formulations has a unique profile. Both offer a convenient and socially acceptable route of administration. Recognition of seizure clusters and timing of proper administration are key to successful use of rescue therapy. Pharmacists' counseling plays an important role in reinforcing when and how to appropriately administer rescue therapies and the importance of consistently using rescue treatment when indicated to promote effective management. This review includes resources for pharmacists, patients, and caregivers; reviews currently available treatments; and discusses seizure action plans that support effective treatment of seizure clusters.

Clinical profile, management and risk factors for seizure-related burn injuries among patients with epilepsy in southwest China

Objective

The epidemiological information associated with seizure-related burn injuries is lacking in China. Therefore, this study aims to analyze the clinical profile, management, outcome, and risk factors of burns that are directly caused by seizures among epileptic patients, and identify the epidemiological characteristics to develop effective preventive strategies.

Methods

This study was conducted between January 2002 and December 2022 in a large Chinese burn center. Data including clinical profile, wound treatment, and outcome were analyzed. A multiple linear regression was used to screen the risk factors for the length of hospital stay (LOS), and a multiple logistic regression was used to screen the contributory factors for the amputation.

Results

A total of 184 burn patients (55.98 % females) were enrolled, with a 0.78 % incidence rate during the study period. The mean age of the patients was 36.16 years (SD: 17.93). Patients aged 20-29 were the most affected age groups (23.37 %). Most burns were caused by flame, accounting for 60.33 % (111/184) of all cases. In total, 76.09 % of the 184 patients underwent at least one operation, and 35 patients (19.02 %) still required amputation during the study period. Burn sites (hands) had the greatest impact on amputation (OR = 3.799), followed by flame burns (OR = 3.723). The mean LOS/TBSA was 6.90 ± 8.53 d, and a larger TBSA, full-thickness burns, and a higher number of operations were identified as the risk factors for a longer LOS. There was one death among the 184 patients, with a mortality rate of 0.54 %.

Conclusion

This study demonstrates that burn injuries are extremely harmful to individuals with epilepsy in China because they are at high risk of amputation and disability. Effective healthcare education and preventive programs that focus on lifestyle modifications and seizure control should be implemented to reduce the burn incidence in these populations.

Prospective validation of a seizure diary forecasting falls short

OBJECTIVE

Recently, a deep learning AI model forecasted seizure risk using retrospective seizure diaries with higher accuracy than random forecasts. The present study sought to prospectively evaluate the same algorithm.

METHODS

We recruited a prospective cohort of 46 people with epilepsy; 25 completed sufficient data entry for analysis (median 5 months). We used the same AI method as in our prior study. Group-level and individual-level Brier Skill Scores (BSS) compared random forecasts and simple moving average forecasts to the AI.

RESULTS

The AI had an AUC of 0.82. At the group level, the AI outperformed random forecasting (BSS=0.53). At the individual level, AI outperformed random in 28% of cases. At the group and individual level, the moving average outperformed the AI. If pre-enrollment (non-verified) diaries (with presumed under-reporting) were included, the AI significantly outperformed both comparators. Surveys showed most did not mind poor quality LOW-RISK or HIGH-RISK forecasts, yet 91% wanted access to these forecasts.

SIGNIFICANCE

The previously developed AI forecasting tool did not outperform a very simple moving average forecasting this prospective cohort, suggesting that the AI model should be replaced.

Return to full baseline functionality after repeated intermittent use of midazolam nasal spray in patients with seizure clusters: Post hoc analysis of an open-label extension trial

OBJECTIVE

To characterize the time to return to full baseline functionality (RTFBF) in seizure cluster episodes (SCEs) treated with one or two midazolam nasal spray (MDZ-NS/Nayzilam®) doses over the course of repeated intermittent use in patients with seizure clusters (SCs).

METHODS

Post hoc analysis of an open-label extension trial in patients (≥12 years) with SCs (ARTEMIS-2/P261-402: NCT01529034, 2011-004109-25). Caregivers administered MDZ-NS 5 mg when patients experienced an SC; a second 5-mg dose could be given if seizures did not terminate within 10 min or recurred within 10 min-6 h.

OUTCOMES

time to RTFBF within 24 h of MDZ-NS administration in SCEs treated with one or two doses, overall (all treated SCEs), and by number of treated SCEs for each patient over the course of the trial (Kaplan-Meier analyses). Time to RTFBF was assessed from the time of MDZ-NS administration in SCEs treated with one dose, and from the time of the second dose in SCEs treated with two doses.

RESULTS

One thousand nine hundred ninety-six treated SCEs (one dose: 1,201 [60.2%]; two doses: 795 [39.8%]) in 161 patients were evaluable. In SCEs treated with one or two doses, RTFBF within 24 h of MDZ-NS administration was observed in 97.2% and 94.2% of patients; the estimated median time was 1.2 and 1.3 h and stable from 1 to 45 treated SCEs. The RTFBF profile was generally similar in SCEs treated with one or two doses (30% of patients estimated to have RTFBF within 30 min, almost 50% within 1 h); the proportion of patients with RTFBF between 2 and 6h was slightly higher with one versus two doses.

SIGNIFICANCE

In almost all patients, RTFBF was observed within 24 h of MDZ-NS administration. The median time to RTFBF was similar in SCEs treated with one or two doses, and stable over the course of repeated intermittent use. Thus, dose (5 or 10 mg) does not seem to be a key influencer of time for RTFBF after repeated intermittent use.

Individualized Seizure Cluster Prediction Using Machine Learning and Chronic Ambulatory Intracranial EEG

Epilepsy patients often experience acute repetitive seizures, known as seizure clusters, which can progress to prolonged seizures or status epilepticus if left untreated. Predicting the onset of seizure clusters is crucial to enable patients to receive preventative treatments. Additionally, studying the patterns of seizure clusters can help predict the seizure type (isolated or cluster) after observing a just occurred seizure. This paper presents machine learning models that use bivariate intracranial EEG (iEEG) features to predict seizure clustering. Specifically, we utilized relative entropy (REN) as a bivariate feature to capture potential differences in brain region interactions underlying isolated and cluster seizures. We analyzed a large ambulatory iEEG dataset collected from 15 patients and spanned up to 2 years of recordings for each patient, consisting of 3341 cluster seizures (from 427 clusters) and 369 isolated seizures. The dataset's substantial number of seizures per patient enabled individualized analyses and predictions. We observed that REN was significantly different between isolated and cluster seizures in majority of the patients. Machine learning models based on REN: 1) predicted whether a seizure will occur soon after a given seizure with up to 69.5% Area under the ROC Curve (AUC), 2) predicted if a seizure is the first one in a cluster with up to 55.3% AUC, outperforming baseline techniques. Overall, our findings could be beneficial in addressing the clinical burden associated with seizure clusters, enabling patients to receive timely treatments and improving their quality of life.

Predicting seizure clustering in the epilepsy monitoring unit: A multivariable analysis

INTRODUCTION

Seizure clustering, is the most frequently reported adverse event in epilepsy monitoring unit (EMU) safety studies which, can also potentiate other adverse events, such as falls, status epilepticus, and increased length of stay. The purpose of this study is to determine variables associated with increased risk of seizure clustering among patients admitted to the EMU.

METHODS

A retrospective review of patients admitted to the EMU over a two-year period was completed. Data collected included patient demographics, types of epilepsy, seizure frequency, anti-seizure medications (ASMs) and hospital and EMU course including incidence of seizure clustering.

RESULTS

Two hundred seven patients were included in our study; of these, ninety patients experienced two or more seizures in a 24-hour period (24SC), and 68 patients experienced two or more seizures in a 4-hour period (4SC). Logistic regression analysis associated the absence of long-acting ASM with increased clustering within the 4SC group (p = 0.038). For every additional ASM taken by a patient at home, the odds of seizure clustering increased by 81% in the 4SC group (p = 0.009) and by 61% in the 24SC group (p = 0.022). In addition, patients with a diagnosis of temporal lobe epilepsy had some association with clustering in the 24SC group (p = 0.061).

CONCLUSION

Our data showed that long-acting ASMs can be protective against seizure clustering. Furthermore, patients with temporal lobe epilepsy, and those on increased numbers of ASMs, were more likely to experience seizure clustering when undergoing medication withdrawal during an EMU evaluation.

Treatment of Seizure Clusters in Epilepsy: A Narrative Review on Rescue Therapies

Epilepsy is a common neurological disorder in the United States, affecting approximately 1.2% of the population. Some people with epilepsy may experience seizure clusters, which are acute repetitive seizures that differ from the person's usual seizure pattern. Seizure clusters are unpredictable, are emotionally burdensome to patients and caregivers (including care partners), and require prompt treatment to prevent progression to serious outcomes, including status epilepticus and associated morbidity (e.g., lacerations, fractures due to falls) and mortality. Rescue medications for community use can be administered to terminate a seizure cluster, and benzodiazepines are the cornerstone of rescue treatment. Despite the effectiveness of benzodiazepines and the importance of a rapid treatment approach, as many as 80% of adult patients do not use rescue medication to treat seizure clusters. This narrative review provides an update on rescue medications used for treatment of seizure clusters, with an emphasis on clinical development and study programs for diazepam rectal gel, midazolam nasal spray, and diazepam nasal spray. Results from long-term clinical trials have shown that treatments for seizure clusters are effective. Intranasal benzodiazepines provide ease of use and patient and caregiver satisfaction in pediatric and adult patients. Adverse events attributed to acute rescue treatments have been characterized as mild to moderate, and no reports of respiratory depression have been attributed to treatment in long-term safety studies. The implementation of an acute seizure action plan to facilitate optimal use of rescue medications provides an opportunity for improved management of seizure clusters, allowing those affected to resume normal daily activities more quickly.

Quantifying and controlling the impact of regression to the mean on randomized controlled trials in epilepsy

OBJECTIVE

Randomized controlled trials (RCTs) in epilepsy for drug treatments are plagued by high costs. One potential remedy is to reduce placebo response via better control over regression to the mean (RTM). Here, RTM represents an initial observed seizure rate higher than the long-term average, which gradually settles closer to the average, resulting in apparent response to treatment. This study used simulation to clarify the relationship between eligibility criteria and RTM.

METHODS

Using a statistically realistic seizure diary simulator, the impact of RTM on placebo response and trial efficacy was explored by varying eligibility criteria for a traditional treatment phase II/III RCT for drug-resistant epilepsy.

RESULTS

When the baseline period was included in the eligibility criteria, increasingly larger fractions of RTM were observed (25%-47% vs. 23%-25%). Higher fractions of RTM corresponded with higher expected placebo responses (50% responder rate [RR50]: 2%-9% vs. 0%-8%) and lower statistical efficacy (RR50: 47%-67% vs. 47%-81%). The exclusion of baseline from eligibility criteria was shown to decrease the number of patients needed by roughly 30%.

SIGNIFICANCE

The manipulation of eligibility criteria for RCTs has a predictable and important impact on RTM, and therefore on placebo response; the difference between drug and placebo was more easily detected. This in turn impacts trial efficacy and therefore cost. This study found dramatic improvements in efficacy and cost when baseline was not included in eligibility.

Perceived seizure risk in epilepsy: Chronic electronic surveys with and without concurrent electroencephalography

OBJECTIVE

Previous studies suggested that patients with epilepsy might be able to forecast their own seizures. This study aimed to assess the relationships between premonitory symptoms, perceived seizure risk, and future and recent self-reported and electroencephalographically (EEG)-confirmed seizures in ambulatory patients with epilepsy in their natural home environments.

METHODS

Long-term e-surveys were collected from patients with and without concurrent EEG recordings. Information obtained from the e-surveys included medication adherence, sleep quality, mood, stress, perceived seizure risk, and seizure occurrences preceding the survey. EEG seizures were identified. Univariate and multivariate generalized linear mixed-effect regression models were used to estimate odds ratios (ORs) for the assessment of the relationships. Results were compared with the seizure forecasting classifiers and device forecasting literature using a mathematical formula converting OR to equivalent area under the curve (AUC).

RESULTS

Fifty-four subjects returned 10 269 e-survey entries, with four subjects acquiring concurrent EEG recordings. Univariate analysis revealed that increased stress (OR = 2.01, 95% confidence interval [CI] = 1.12-3.61, AUC = .61, p = .02) was associated with increased relative odds of future self-reported seizures. Multivariate analysis showed that previous self-reported seizures (OR = 5.37, 95% CI = 3.53-8.16, AUC = .76, p < .001) were most strongly associated with future self-reported seizures, and high perceived seizure risk (OR = 3.34, 95% CI = 1.87-5.95, AUC = .69, p < .001) remained significant when prior self-reported seizures were added to the model. No correlation with medication adherence was found. No significant association was found between e-survey responses and subsequent EEG seizures.

SIGNIFICANCE

Our results suggest that patients may tend to self-forecast seizures that occur in sequential groupings and that low mood and increased stress may be the result of previous seizures rather than independent premonitory symptoms. Patients in the small cohort with concurrent EEG showed no ability to self-predict EEG seizures. The conversion from OR to AUC values facilitates direct comparison of performance between survey and device studies involving survey premonition and forecasting.

Acute seizure therapies in people with epilepsy: Fact or fiction? A U.S. Perspective

Patients with epilepsy (PWE) may experience seizure emergencies including acute repetitive seizures despite chronic treatment with daily antiseizure medications. Seizures may adversely impact routine daily activities and/or healthcare utilization and may impair the quality of life of patients with epilepsy and their caregivers. Seizures often occur at home, school, or work in a community setting. Appropriate treatment that is readily accessible for patients with seizure urgencies and emergencies is essential outside the hospital setting. When determining the best acute antiseizure therapy for PWE, clinicians need to consider all of the available rescue medications and their routes of administration including the safety and efficacy profiles. Benzodiazepines are a standard of care as a rescue therapy, yet there are several misconceptions about their use and safety. Reevaluating potential misconceptions and formulating best practices are necessary to maximize usage for each available option of acute therapy. We examine common beliefs associated with traditional use of acute seizure therapies to refute or support them based on the current level of evidence in the published literature.

Experience of the new seizure diary in the Free State and Northern Cape

BACKGROUND

Epilepsy is a neurological disease affecting adults and children globally. A seizure diary is one of the self-management tools for tracking seizures. This study aims to ascertain the experience of a new seizure diary by persons completing the diary in the Free State and Northern Cape of South Africa.

METHODS

Adult patients with epilepsy attending Universitas Academic Hospital epilepsy clinic in Bloemfontein, clinics in Kimberley and the casualty department of Kimberley hospital (Robert Mangaliso Sobukwe hospital) received a new seizure diary. After using the diary for 6 months, participants (patients, relatives or caregivers) completed a questionnaire.

RESULTS

A total of 139 epilepsy patients received a new seizure diary; 67 previously diary-unexposed participants and 33 participants who had previous exposure to a seizure diary. The majority of participants, namely 91% of previously diary-unexposed and 84.9% of participants who had previous exposure to the seizure diary, understood the new seizure diary. Participants who had previous exposure to a seizure diary were predominantly very positive about the new diary because it had more information. However, 21.2% indicated that they preferred the old one because it was easier to complete.

CONCLUSION

Patients, caregivers or relatives from both groups used the new seizure diary and provided important information about their experience with the new diary. Despite a few complaints about using the new diary, most participants who had previous exposure to a seizure diary preferred the new seizure diary.Contribution: This study explored participants' opinions of the new seizure diary.

Overcoming barriers to the management of seizure clusters: ease of use and time to administration of rescue medications

INTRODUCTION

Patients with epilepsy can experience seizure clusters (acute repetitive seizures), defined as intermittent, stereotypic episodes of frequent seizure activity that are distinct from typical seizure patterns. There are three FDA-approved rescue medications, diazepam rectal gel, midazolam nasal spray, and diazepam nasal spray, that can be administered to abort a seizure cluster in a nonmedical, community setting. Despite their effectiveness and safety, rescue medications are underutilized, and patient/caregiver experiences and perceptions of ease of use may constitute a substantial barrier to greater utilization.

AREAS COVERED

The literature on rescue medications for seizure clusters is reviewed, including the effectiveness and safety, with an emphasis on ease and timing of treatment and associated outcomes. Barriers to greater utilization of rescue medication and the role of seizure action plans are discussed.

EXPERT OPINION

Intranasal rescue medications are easier to use and can be administered more rapidly than other routes (rectal, intravenous). Importantly, rapid administration of intranasal rescue medications has been associated with shorter durations of seizure activity as compared with rectal/intravenous routes. Intranasal rescue medications are also easy to use and socially acceptable. These factors potentially remove or reduce barriers to use and optimize the management of seizure clusters.

Use of intranasal rescue therapy for seizure clusters in students with epilepsy: Nurses' knowledge, perceptions, and practice

School nurses play a crucial role in the prompt, appropriate response to epilepsy-related seizure emergencies among students in the school setting. Two intranasal benzodiazepine rescue therapies are now approved and offer potential benefits of being easy to use and socially acceptable. In July 2021, a survey was sent to 49,314 US school nurses to assess knowledge, perceptions, and practice with seizure rescue therapy. Responses were received from 866 (1.8% response rate). Of respondents, 45.7% had used rectal diazepam gel; 9.3%, midazolam nasal spray; and 6.0%, diazepam nasal spray. The majority (58.7%) had not delegated authority to administer rescue therapy, with state/local regulations and lack of willingness of school personnel being the most common barriers to delegation (37.7% and 20.1%, respectively). Additional training of nurses and school staff and progress on delegation policies may help optimize appropriate use of intranasal rescue therapy for seizures and enhance care of students with epilepsy in schools.

Efficacy of a pre-specified timeline-based treatment protocol in children with acute repetitive seizures or seizure clusters

Objectives

Acute repetitive seizures (ARSs) are one of the few commonly encountered neurological emergencies in children. There is a need for an appropriate timeline-based treatment protocol, which will be shown to be safe and efficacious in a clinical study.

Materials and Methods

This was a retrospective chart review to determine the efficacy of a pre-specified treatment protocol for the management of ARSs in children aged 1-18 years. The treatment protocol was specifically applied in children with a diagnosis of epilepsy and not critically ill, who met the criteria for ARSs, with the exemption of new onset of ARSs. The first tier of treatment protocol focused on intravenous lorazepam, optimization of dose of existing anti-seizure medications (ASMs), and control of triggers like acute febrile illness, while second-tier focused on adding one or two additional ASMs, commonly used in cases with seizure clusters or status epilepticus.

Results

We included the first 100 consecutive patients (7.6 ± 3.2 years, 63% boys). Our treatment protocol was successful in 89 patients (58 and 31 required first-tier and second-tier treatment). The absence of pre-existing drug-resistant epilepsy and the presence of acute febrile illness as a triggering factor (P = 0.02 and 0.03) were associated with the success of the first tier of the treatment protocol. Excessive sedation (n = 29), incoordination (n = 14), transient gait instability (n = 11), and excessive irritability (n = 5) were the most common adverse effects observed during the initial 1 week.

Conclusion

This pre-specified treatment protocol is safe and efficacious in controlling ARSs in cases with established epilepsy who are not critically sick. External validation from other parts of the world/centers and a more diverse epilepsy population are required before generalizing the protocol into clinical practice.

Perceived seizure risk in epilepsy â€" Chronic electronic surveys with and without concurrent EEG

Objective

Previous studies suggested that patients with epilepsy might be able to fore-cast their own seizures. We sought to assess the relationships of premonitory symptoms and perceived seizure risk with future and recent self-reported and EEG-confirmed seizures in the subjects living with epilepsy in their natural home environments.

Methods

We collected long-term e-surveys from ambulatory patients with and without concurrent EEG recordings. Information obtained from the e-surveys included medication compliance, sleep quality, mood, stress, perceived seizure risk and seizure occurrences preceding the survey. EEG seizures were identified. Univariate and multivariate generalized linear mixed-effect regression models were used to estimate odds ratios (ORs) for the assessment of the relationships. Results were compared with device seizure forecasting literature using a mathematical formula converting OR to equivalent area under the curve (AUC).

Results

Sixty-nine subjects returned 12,590 e-survey entries, with four subjects acquiring concurrent EEG recordings. Univariate analysis revealed increased stress (OR = 2.52, 95% CI = [1.52, 4.14], p < 0.001) and decreased mood (0.32, [0.13, 0.82], 0.02) were associated with increased relative odds of future self-reported seizures. On multivariate analysis, previous self-reported seizures (4.24, [2.69, 6.68], < 0.001) were most strongly associated with future self-reported seizures, and high perceived seizure risk (3.30, [1.97, 5.52], < 0.001) remained significant when prior self-reported seizures were added to the model. No significant association was found between e-survey responses and subsequent EEG seizures.

Significance

It appears that patients may tend to self-forecast seizures that occur in sequential groupings. Our results suggest that low mood and increased stress may be the result of previous seizures rather than independent premonitory symptoms. Patients in the small cohort with concurrent EEG showed no ability to self-predict EEG seizures. The conversion from OR to AUC values facilitates direct comparison of performance between survey and device studies involving survey premonition and forecasting.

Key points

Long-term e-surveys data and concurrent EEG signals were collected across three study sites to assess the ability of the patients to self-forecast their seizures.Patients may tend to self-forecast self-reported seizures that occur in sequential groupings.Factors, such as mood and stress, may not be independent premonitory symptoms but may be the consequence of recent seizures.No ability to self-forecast EEG confirmed seizures was observed in a small cohort with concurrent EEG validation.A mathematic relation between OR and AUC provides a means to compare forecasting performance between survey and device studies.

Written seizure action plans for adult patients with epilepsy: Distilling insights from emergency action plans for other chronic conditions

Seizure emergencies and potential emergencies, ranging from seizure clusters to prolonged seizure and status epilepticus, may affect adults with epilepsy despite stable antiseizure therapy. Seizure action plans (SAPs) are designed for patients and their caregivers/care partners to provide guidance on the individualized treatment plan, including response to potential seizure emergencies and appropriate use of rescue therapy. The use of pediatric SAPs is common (typically required by schools), however, most adults with epilepsy do not have a plan. Patient-centered action plans are integral to care for other chronic conditions and may offer insights applicable to the care of adults with epilepsy. This review analyzes the potential benefits of action plans for medical conditions by exploring their utility in conditions such as asthma, diabetes, chronic obstructive pulmonary disease, heart disease, and opioid overdose. Evidence across these conditions substantiates the value of action plans for patients, and the benefits of adult SAPs in epilepsy are emerging. Because wide implementation of SAPs has faced barriers, other conditions may provide insights that are relevant to implementing SAPs in epilepsy. Based on these analyses, we propose concrete steps to improve the use of SAPs among adults. A recent consensus statement promoting the use of formal SAPs in epilepsy and advances in rescue therapy delivery methods provides support to engage patients around the value of SAPs. The precedent for use of SAPs for pediatric epilepsy patients serves as the foundation to support increased usage in adults. Seizure action plans in the context of improved clinical outcomes are expected to reduce healthcare utilization, improve patient quality of life, and optimize epilepsy management.

Flexible realistic simulation of seizure occurrence recapitulating statistical properties of seizure diaries

OBJECTIVE

A realistic seizure diary simulator is currently unavailable for many research needs, including clinical trial analysis and evaluation of seizure detection and seizure-forecasting tools. In recent years, important statistical features of seizure diaries have been characterized. These include (1) heterogeneity of individual seizure frequencies, (2) the relation between average seizure rate and standard deviation, (3) multiple risk cycles, (4) seizure clusters, and (5) limitations on inter-seizure intervals. The present study unifies these features into a single model.

METHODS

Our approach, Cyclic Heterogeneous Overdispersed Clustered Open-source L-relationship Adjustable Temporally limited E-diary Simulator (CHOCOLATES) is based on a hierarchical model centered on a gamma Poisson generator with several modifiers. This model accounts for the aforementioned statistical properties. The model was validated by simulating 10 000 randomized clinical trials (RCTs) of medication to compare with 23 historical RCTs. Metrics of 50% responder rate (RR50) and median percent change (MPC) were evaluated. We also used CHOCOLATES as input to a seizure-forecasting tool to test the flexibility of the model. We examined the area under the receiver-operating characteristic (ROC) curve (AUC) for test data with and without cycles and clusters.

RESULTS

The model recapitulated typical findings in 23 historical RCTs without the necessity of introducing an additional "placebo effect." The model produced the following RR50 values: placebo: 17 ± 4%; drug 38 ± 5%; and the following MPC values: placebo: 13 ± 6%; drug 40 ± 4%. These values are similar to historical data: for RR50: placebo, 21 ± 10%, drug: 43 ± 13%; and for MPC: placebo: 17 ± 10%, drug: 41 ± 11%. The seizure forecasts achieved an AUC of 0.68 with cycles and clusters, whereas without them the AUC was 0.51.

SIGNIFICANCE

CHOCOLATES represents the most realistic seizure occurrence simulator to date, based on observations from thousands of patients in different contexts. This tool is open source and flexible, and can be used for many applications, including clinical trial simulation and testing of seizure-forecasting tools.

The Evaluation of the Efficacy and Safety of Midazolam Nasal Spray in Patients With Seizure Clusters: A Systematic Review and Meta-Analysis

Midazolam nasal spray (MDZ-NS) is a new emerging rescue medication that suppresses epileptic seizures. Until now, few studies, pharmacokinetic (PK) and pharmacodynamic (PD) profiles, and clinical trials have shown that midazolam nasal spray could become an effective and promising alternative to conventional routes (intravenous {IV}/rectal). Therefore, we thought of conducting a systematic review and meta-analysis of midazolam (MDZ) to assess its potential outcomes. The analysis was also evaluated based on the pharmacokinetic (PK) and pharmacodynamic (PD) profiles of midazolam nasal spray. A systematic literature search was carried out through various databases to identify studies of accounted outcomes of midazolam nasal spray (MDZ-NS). Randomized and other studies of patients (12 years or older) with seizure clusters (SCs) were included. A total of three full-text articles were considered for systematic review and meta-analysis as per the inclusion and exclusion criteria. The 5 mg MDZ-NS was observed to be equally safe as a placebo, and the risk ratio (RR) was 1.01 (95% confidence interval (CI): 0.67-1.53). After the administration of MDZ-NS, either the patients remained seizure-free for six hours or more or the seizure was terminated within 10 minutes and had no recurrence between 10 minutes and six hours. The risk ratio (RR) obtained was 1.54 (95% CI: 1.25-1.91). The result was statistically significant as a higher success rate was observed with the use of 5 mg midazolam nasal spray compared to placebo (p < 0.0001). Heterogeneity was not observed in the results of the included studies (inconsistency index {I2}: 0%). The present systematic review and meta-analysis demonstrated that 5 mg midazolam nasal spray was efficacious in treating patients with seizure clusters and is well-tolerated. Also, its use is relatively safe.

Prevalence and Predictors of Seizure Clusters in Pediatric Patients With Epilepsy: The Harvard-Yale Pediatric Seizure Cluster Study

BACKGROUND

Determine the prevalence of seizure clusters (two or more seizures in six hours), use of rescue medications, and adverse outcomes associated with seizure clusters in pediatric patients with a range of epilepsy severities, and identify risk factors predictive of seizure clusters.

METHODS

Prospective observational two-center study, including phone call and seizure diary follow-up for 12 months in patients with epilepsy aged one month to 18 years. We classified patients into three risk groups based on seizures within the prior year: high, seizure cluster (two or more seizures within one day); intermediate, at least one seizure but no days with two or more seizures; low, no seizures.

RESULTS

One-third (32.3%; high risk, 72.4%; intermediate risk, 30.4%; low risk, 3.1%) of 297 patients had a seizure cluster during the study, including half (46.2%) of the patients with active seizures at baseline (intermediate- and high-risk groups combined). Emergency room visits or injuries were no more likely due to a seizure cluster than an isolated seizure. Rescue medications were utilized in 15.8% of patients in the high-risk group and 19.2% in the intermediate-risk group. History of status epilepticus (adjusted odds ratio [aOR], 2.13; confidence interval [CI], 1.09 to 4.16]), seizure frequency greater than four per month (aOR, 4.27; CI, 1.92 to 9.50), and high-risk group status (aOR, 6.42; CI, 2.97 to 13.87) were associated with greater odds of seizure cluster.

CONCLUSIONS

Seizure clusters are common in pediatric patients with epilepsy. High seizure frequency was the strongest predictor of clusters. Rescue medications were underutilized. Future studies should evaluate the applicability and effectiveness of these medications for optimization of pediatric seizure cluster treatment and reduction of seizure-related emergency department visits, injuries, and mortality.

The effect of butylphthalide on aminoacid content in the brain of epileptic mice

BACKGROUND

The aim of this study is to observe the effect of butylphthalide (NBP) on the amino acid content in the brain of epileptic mice.

METHODS

NBP was injected intraperitoneally into the mice, and acute epileptic mice models were made after 30 minutes. The change of the four amino (aspartic acid, gamma-aminobutyric acid, glutamate, glycine) content in the brain of the epileptic mice was investigated.

RESULTS

The contents of Glu and Glu/GABA (control group: 38.78, NBP high-dose group: 5.52) in the NBP high-dose group were lower compared with the control group. The difference was statistically significant.

CONCLUSIONS

NBP could regulate the balance of excitement and inhibition systems by reducing the contents of Glu and Glu/GABA, which might relieve seizures.

Significant improvements in SEIzure interVAL (time between seizure clusters) across time in patients treated with diazepam nasal spray as intermittent rescue therapy for seizure clusters

OBJECTIVE

Intermittent rescue therapy may be used for seizure clusters, which are clinical emergencies that may persist ≥24 h and increase risk of status epilepticus, emergency room visits, and reduced quality of life for patients with epilepsy. Beyond effectiveness for aborting seizure clusters, no data exist on how intermittent rescue therapy may impact the long-term natural course of seizure clusters. This novel analysis explores SEIzure interVAL (SEIVAL; time between seizure clusters) in patients from a long-term safety study of diazepam nasal spray (Valtoco) to assess SEIVAL changes with intermittent rescue therapy across time.

METHODS

Patients were aged 6-65 years. Age- and weight-based doses of diazepam nasal spray were administered during a 12-month treatment period with an optional follow-up period. SEIVAL was evaluated in patients receiving two or more doses of diazepam nasal spray using 90-day periods.

RESULTS

Of 163 treated patients, 151 had one or more SEIVALs. One hundred twenty had SEIVALs in Period 1 and one or more other periods. An increase in SEIVAL was noted from Period 1 compared with all subsequent periods (p ≤ .001). A consistent cohort (n = 76) had one or more SEIVALs in each of Periods 1-4 (360 days); mean SEIVALs increased significantly (p < .01) from 12.2 days (Period 1) to 25.7 days (Period 4). Similar SEIVAL patterns occurred when repeat doses within a seizure cluster were eliminated and irrespective of age group, treatment duration, and change to concomitant medications. In adults, Quality of Life in Epilepsy scores were maintained with increased SEIVALs.

SIGNIFICANCE

Across 12 months, increases in SEIVAL were demonstrated in patients using diazepam nasal spray for seizure cluster treatment in a phase 3 safety study. Increased time between seizure clusters may reflect a previously unrecognized beneficial effect of intermittent rescue therapy. These results generate a range of biological and behavioral hypotheses and warrant exploration of the impact of intermittent rescue therapy.

Current norms and practices in using a seizure diary for managing epilepsy: A scoping review

BACKGROUND

Epilepsy is a chronic and debilitating condition affecting people of all ages in many nations. Healthcare practitioners look for effective ways to track patients' seizures, and a seizure diary is one of the methods used. This scoping review sought to identify current norms and practices for using seizure diaries to manage epilepsy.

METHOD

A scoping review was performed by screening relevant studies and identifying themes, categories and subcategories.

RESULTS

A total of 1125 articles were identified from the database; 46 full-text articles were assessed for eligibility, of which 23 articles were selected. The majority (48%) of the studies were prospective studies. The majority (65%) of the articles were studies conducted in the United States. The themes identified were types of seizure diaries used in clinical practice, contents and structure of a standardised seizure diary, the use and efficacy of seizure diaries in medicine and challenges relating to using a seizure diary for patient management.

CONCLUSION

The study revealed that a seizure diary remains a relevant tool in managing epilepsy. The two forms of diaries in use are electronic and paper-based diaries. The high cost of data and the expensive devices required to access electronic diaries make it unsuitable in a resource-limited setting. Despite its disadvantages, imperfections and inadequacies, the paper-based diary is still relevant for managing patients with epilepsy in resource-limited settings.Contribution: This study reviewed the literature to find the current norms and practices in using seizure diaries. The benefits of the different formats were emphasised.

Consequences: Bench to home

Seizure clusters (also referred to as acute repetitive seizures) consist of several seizures interspersed with brief interictal periods. Seizure clusters can break down γ-aminobutyric acidergic (GABAergic) inhibition of dentate granule cells, leading to hyperactivation. Functional changes to GABAA receptors, which play a vital neuroinhibitory role, can include altered GABAA receptor subunit trafficking and cellular localization, intracellular chloride accumulation, and dysregulation of proteins critical to chloride homeostasis. A reduction in neuroinhibition and potentiation of excitatory neurotransmission in CA1 pyramidal neurons represent pathological mechanisms that underlie seizure clusters. Benzodiazepines are well-established treatments for seizure clusters; however, there remain barriers to appropriate care. At the clinical level, there is variability in seizure cluster definitions, such as the number and/or type of seizures associated with a cluster as well as the interictal duration between seizures. This can lead to delays in diagnosis and timely treatment. There are gaps in understanding between clinicians, their patients, and caregivers regarding acute treatment for seizure clusters, such as the use of rescue medications and emergency services. This lack of consensus to define seizure clusters in addition to a lack of education for appropriate treatment can affect quality of life for patients and place a greater burden on patient families and caregivers. For patients with seizure clusters, the sense of unpredictability can lead to continuous traumatic stress, during which patients and families live with a heightened level of anxiety. Clinicians can affect patient quality of life and clinical outcomes through improved seizure cluster education and treatment, such as the development and implementation of a personalized seizure action plan as well as prescriptions for suitable rescue medications indicated for seizure clusters and instructions for their proper use. In all, the combination of targeted therapy along with patient education and support can improve quality of life.

Use of new intranasal benzodiazepines at a typical adult epilepsy center

OBJECTIVE

The aim of this study was to review out-of-hospital use of intranasal diazepam and midazolam for treatment of acute repetitive seizures (ARS) at a typical adult epilepsy center.

METHODS

Data were collected through chart review and by telephone calls to either the patient or the caregiver regarding drug effectiveness, overall satisfaction, and adverse events.

RESULTS

We identified 96 patients who were prescribed either benzodiazepine. Thirty-nine patients in the diazepam group and 38 patients in the midazolam group were able to be contacted and were included in the study. Sixty-two percent of patients in the diazepam group and 55% of patients in the midazolam group had used the medication at the time of data collection. Of these patients, 83% of patients in the diazepam group and 85% of patients in the midazolam group reported cessation of seizures after either the first or second dose. In comparison of the average patient satisfaction between intranasal diazepam and midazolam, there was no statistical significance (4.25 ± 1.22 vs 3.95 ± 1.35; p = 0.42). Adverse events were minor, included fatigue, nasal discomfort, headache, and dizziness.

DISCUSSION

The use of the two new intranasal benzodiazepines was roughly divided equally. Slightly more than half of the patients who were prescribed the medication had used it. The overall satisfaction of the two medications was comparable. These findings highlight the principal usability of intranasal diazepam and midazolam in adults with ARS.

Economic aspects of treating seizure clusters

Seizure clusters may initiate a chain of events that have economic as well as clinical consequences. The potential economic consequences of seizure clusters must be weighed against the cost of medication to attenuate them. This is true both for individual patients and for society. Data needed for economic analyses include the chance that a cluster will progress to an adverse outcome, such as a need for emergency care, the costs of such an outcome, the cost of a rescue medication (RM), and the effectiveness of the RM. Indirect costs, such as lost employment for patients and caregivers, must also be considered. Several types of economic analyses can be used to determine costs and benefits of a medical intervention. There are studies comparing different RMs from an economic perspective, but there is little direct information on the costs of using an RM versus allowing clusters to run their course. However, the high expense of consequences of seizure clusters makes it likely that effective RMs will make economic as well as medical sense for many patients.

Quality-of-life results in adults with epilepsy using diazepam nasal spray for seizure clusters from a long-term, open-label safety study

BACKGROUND

The impact of seizure clusters and the use of intermittent rescue therapy for clusters on the quality of life (QoL) of patients with epilepsy has not been widely studied. The present analysis assessed QoL as a secondary endpoint among adult patients with seizure clusters enrolled in a long-term, phase 3, open-label safety study (NCT02721069) of diazepam nasal spray (Valtoco®). The QoL aspect of patients in this study has not been previously published.

METHODS

The 12-month safety study of diazepam nasal spray enrolled patients aged 6-65 years with seizure clusters. Adults aged ≥18 years completed the Quality of Life in Epilepsy (QOLIE)-31-P at baseline (day 0) and days 30, 150, 270, and 365. This instrument includes questions about patient health and daily activities with numeric values (1-100) assigned to responses; higher scores indicate better QoL. The QOLIE-31-P includes 7 subscales: Seizure Worry, Overall QoL, Emotional Well-Being, Energy/Fatigue, Cognitive Functioning, Medication Effects, and Social Functioning; an Overall Score is calculated as a weighted composite of the 7 subscales. Comparisons were made between subgroups of patients who had frequent (≥2) and infrequent (<2) monthly dosing of diazepam nasal spray and those whose doses were administered by the patient or a care partner. This safety study was not powered to assess efficacy endpoints; descriptive statistics were calculated across time points. In addition, safety measures, including treatment-emergent adverse events, are reported.

RESULTS

Seventy-two adults who responded to the QOLIE-31-P were included in the analyses. Mean QOLIE-31-P scores were stable or increased across time points. The mean total scores increased from day 0 to day 365 by 5.2 among patients providing data for ≥1 time point (follow-up group) and 2.2 among patients providing data at all time points (QOLIE all-assessments subgroup). Subscale means for Seizure Worry and Social Functioning showed the greatest numeric increase from baseline. Mean QOLIE-31-P scores were similar in all subgroups. The safety profile in the follow-up group was similar to that seen in all study adults.

CONCLUSIONS

Adults with refractory epilepsy who were treated with diazepam nasal spray for seizure clusters maintained or improved QOLIE subscale scores across the 12-month study period. Seizure Worry and Social Functioning subscale scores increased over time, suggesting improvement in these domains for this population with intractable epilepsy. Changes among subscale results suggest differences in sensitivity to the use of an intermittent treatment. The potential to improve patient function with treatment for seizure clusters warrants further study.