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Maltseva M, Rosenow F, von Podewils F, Habermehl L, Langenbruch L, Bierhansl L, Knake S, Schulz J, Gaida B, Kämppi L, Mann C, Strzelczyk A. Predictors for and use of rescue medication in adults with epilepsy: A multicentre cross-sectional study from Germany. Seizure 2024; 118:58-64. [PMID: 38642445 DOI: 10.1016/j.seizure.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 04/06/2024] [Accepted: 04/06/2024] [Indexed: 04/22/2024] Open
Abstract
BACKGROUND Seizure clusters, prolonged seizures, and status epilepticus are life-threatening neurological emergencies leading to irreversible neuronal damage. Benzodiazepines are current evidence-based rescue therapy options; however, recent investigations indicated the prescription of mainly unsuitable benzodiazepines and inappropriate use of rescue medication. OBJECTIVE To examine current use, satisfaction, and adverse events concerning rescue medication in patients with epilepsy in Germany. PATIENTS AND METHODS The study was conducted at epilepsy centres in Frankfurt am Main, Greifswald, Marburg, and Münster between 10/2020 and 12/2020. Patients with an epilepsy diagnosis were assessed based on a questionnaire examining a 12-month period. RESULTS In total, 486 patients (mean age: 40.5, range 18-83, 58.2 % female) participated in this study, of which 125 (25.7 %) reported the use of rescue medication. The most frequently prescribed rescue medications were lorazepam tablets (56.8 %, n = 71 out of 125), buccal midazolam (19.2 %, n = 24), and rectal diazepam (10.4 %, n = 13). Seizures continuing for over several minutes (43.2 %, n = 54), seizure clusters (28.0 %, n = 35), and epileptic auras (28.0 %, n = 35) were named as indications, while 28.0 % (n = 35) stated they administered the rescue medication for every seizure. Of those continuing to have seizures, 46.0 % did not receive rescue medication. On average, rescue medication prescription occurred 7.1 years (SD 12.7, range 0-66) after an epilepsy diagnosis. CONCLUSIONS Unsuitable oral benzodiazepines remain widely prescribed for epilepsy patients as rescue medication. Patients also reported inappropriate use of medication. A substantial proportion of patients who were not seizure-free did not receive rescue medication prescriptions. Offering each patient at risk for prolonged seizures or clusters of seizures an individual rescue treatment with instructions on using it may decrease mortality and morbidity and increase quality of life. .
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Affiliation(s)
- Margarita Maltseva
- Goethe University Frankfurt, Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany; Alberta Children's Hospital Research Institute & Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Felix Rosenow
- Goethe University Frankfurt, Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Felix von Podewils
- University Hospital Greifswald, Epilepsy Center Greifswald, Department of Neurology, Greifswald, Germany
| | - Lena Habermehl
- Philipps-University Marburg, Epilepsy Center Hessen, Department of Neurology, Marburg, Germany
| | - Lisa Langenbruch
- University of Münster, Epilepsy Center Münster-Osnabrück, Department of Neurology with Institute of Translational Neurology, Münster, Germany; Klinikum Osnabrück, Department of Neurology, Osnabrück, Germany
| | - Laura Bierhansl
- University of Münster, Epilepsy Center Münster-Osnabrück, Department of Neurology with Institute of Translational Neurology, Münster, Germany
| | - Susanne Knake
- Philipps-University Marburg, Epilepsy Center Hessen, Department of Neurology, Marburg, Germany
| | - Juliane Schulz
- University Hospital Greifswald, Epilepsy Center Greifswald, Department of Neurology, Greifswald, Germany
| | - Bernadette Gaida
- University Hospital Greifswald, Epilepsy Center Greifswald, Department of Neurology, Greifswald, Germany
| | - Leena Kämppi
- Helsinki University Hospital and University of Helsinki, Epilepsia Helsinki, European Reference Network EpiCARE, Department of Neurology, Helsinki, Finland
| | - Catrin Mann
- Goethe University Frankfurt, Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Goethe University Frankfurt, Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany.
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Hayakawa Y, Rospo C, Bartmann AP, King A, Roebling R, Chanteux H. Pharmacokinetics of Staccato ® alprazolam in healthy adult participants in two phase 1 studies: An open-label smoker study and a randomized, placebo-controlled ethnobridging study. Epilepsia 2024; 65:887-899. [PMID: 38400813 DOI: 10.1111/epi.17901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 01/11/2024] [Accepted: 01/16/2024] [Indexed: 02/26/2024]
Abstract
OBJECTIVE Staccato® alprazolam is a single-use, drug-device combination delivering alprazolam to the deep lung that is being evaluated as treatment for rapid and early seizure termination. This article reports pharmacokinetic (PK) data from two phase 1 studies of Staccato alprazolam in healthy adult participants. METHODS The smoker study (EPK-002/NCT03516305) was an open-label, nonrandomized, single-dose, PK study in smokers and nonsmokers aged 21-50 years, administered a single inhaled dose of 1 mg Staccato alprazolam. The ethnobridging study (UP0101/NCT04782388) was a double-blind, placebo-controlled study in Japanese, Chinese, and Caucasian participants aged 18-55 years randomized 4:1 to a single inhaled dose of Staccato alprazolam 2 mg or Staccato placebo. RESULTS In the smoker study, 36 participants (18 smokers, 18 nonsmokers) were enrolled and received Staccato alprazolam. Following Staccato administration, alprazolam was rapidly absorbed, with a median time to peak drug plasma concentration (Tmax) of 2 min in both smokers (range = 2-30 min) and nonsmokers (range = 2-60 min). Staccato alprazolam was rapidly absorbed to a similar extent in both smokers and nonsmokers. The most commonly reported treatment-emergent adverse events (TEAEs) were somnolence and dizziness. In the ethnobridging study, 10 participants each of Japanese, Chinese, and Caucasian ethnicities were randomized 4:1 to Staccato alprazolam or Staccato placebo. Following Staccato administration, alprazolam was rapidly absorbed and distributed, with a median Tmax of 1.5-2 min in Japanese (range = 1-2 min), Chinese (range = 1-34 min), and Caucasian (range = 1-120 min) participants. Somnolence and sedation were the most commonly reported TEAEs. In both studies, there were no deaths, and no participants reported serious or severe TEAEs, or discontinued due to TEAEs. SIGNIFICANCE Alprazolam was rapidly absorbed, and therapeutic drug levels were achieved within 2 min postdose when administered to the lung with the Staccato device. Staccato alprazolam was generally well tolerated and displayed a safety profile consistent with that known from other alprazolam applications. No new safety signals were identified.
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Huang F, San X, Liu Q, Zhu H, Xu W. Signal mining and risk analysis of Alprazolam adverse events based on the FAERS database. Sci Rep 2024; 14:7489. [PMID: 38553504 PMCID: PMC10980721 DOI: 10.1038/s41598-024-57909-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 03/22/2024] [Indexed: 04/02/2024] Open
Abstract
This study aims to evaluate the safety of Alprazolam by analyzing the FAERS database, provide data analysis for monitoring adverse drug reactions. This research encompasses adverse event (AE) reports related to Alprazolam from the first quarter of 2004 to the second quarter of 2023. Four signal mining and analysis methods were utilized, including Reporting Odds Ratio (ROR), Proportional Reporting Ratio (PRR), Bayesian Confidence Propagation Neural Network (BCPNN), and Empirical Bayesian Geometric Mean (EBGM). Further exploration was conducted regarding patient characteristics and types of AEs. A total of 23,575 AE reports in which Alprazolam was the primary suspect drug were collected, identifying 347 Preferred Term (PT) signals and 27 System Organ Classes (SOCs). The number of AE reports increased annually, especially in 2015, 2018, 2019, and 2020. The main affected groups were females and the age range of 18 to 45. Psychiatric disorders, Nervous system disorders, and Gastrointestinal disorders were the most common the organ system in which the AEs occurred. There is a certain risk of drug abuse and suicide with Alprazolam. Most notably, several AEs not recorded in the Alprazolam leaflet appeared among the top 30 PTs in signal strength, including but not limited to Benzodiazepine drug level abnormal, Acquired amegakaryocytic thrombocytopenia, Cutaneous T-cell dyscrasia, and Coronary No-reflow Phenomenon. For the first time, AEs related to the cardiovascular system and platelet function were unveiled. The severe AE reports that resulted in "hospitalization" and "death" accounted for 30.96% and 21.86%. This study highlights the risks of suicide and misuse of Alprazolam. Other potential severe or fatal AEs, such as those related to the cardiovascular system, platelet function, and others, require further research to determine their precise mechanisms and risk factors.
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Affiliation(s)
- Feng Huang
- Department of Clinical Laboratory, Kunshan Maternity and Children's Health Care Hospital, Kunshan, 215300, Jiangsu, China
- Department of Clinical Laboratory, The First People's Hospital of Kunshan Affiliated With Jiangsu University, Kunshan, 215300, Jiangsu, China
- Jiangsu Key Laboratory of Medical Science and Laboratory Medicine, School of Medicine, Jiangsu University, Zhenjiang, 212013, Jiangsu, China
| | - Xiao San
- Jiangsu Key Laboratory of Medical Science and Laboratory Medicine, School of Medicine, Jiangsu University, Zhenjiang, 212013, Jiangsu, China
| | - Qingqian Liu
- Department of Clinical Laboratory, The First People's Hospital of Kunshan Affiliated With Jiangsu University, Kunshan, 215300, Jiangsu, China
| | - Haohao Zhu
- Mental Health Center of Jiangnan University, Wuxi Central Rehabilitation Hospital, Wuxi, 214151, Jiangsu, China.
| | - Wenrong Xu
- Jiangsu Key Laboratory of Medical Science and Laboratory Medicine, School of Medicine, Jiangsu University, Zhenjiang, 212013, Jiangsu, China.
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Yılmaz Erol T, İlgezdi Kaya İ, Ur Özçelik E, Aksu S, Şirin NG, Bebek N, Kurt A, Karamürsel S, Baykan B. Acute effect of transcranial direct current stimulation on photoparoxysmal response. Epilepsy Res 2024; 201:107320. [PMID: 38412793 DOI: 10.1016/j.eplepsyres.2024.107320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/22/2024] [Accepted: 02/07/2024] [Indexed: 02/29/2024]
Abstract
INTRODUCTION Transcranial direct current stimulation (tDCS) is a non-invasive technique, used to modify the excitability of the central nervous system. The main mechanism of tDCS is to change the excitability by subthreshold modulation by affecting neuronal membrane potentials in the direction of depolarization or repolarization. tDCS was previously investigated as an alternative adjunctive therapy in patients with epilepsy. We aimed here to investigate the acute effect of tDCS on the photoparoxysmal response (PPR) in EEG. METHODS We enrolled 11 consecutive patients diagnosed with idiopathic generalized epilepsy who had PPR on at least 2 EEGs. Three different procedures, including sham, anodal, and cathodal tDCS were applied to the patients at intervals of one week by placing the active electrode over Oz, for 2 mA, 20 minutes. Spike-wave indices (SWI) were counted by two researchers independently and were compared during intermittent photic stimulation (IPS) on EEGs both before and after the application. RESULTS After cathodal tDCS, SWI increased compared to baseline EEG and sham EEG in 3 patients, and after anodal tDCS, SWI increased in 2 patients. Although the SWI values did not change significantly, 8 patients reported subjectively that the applications were beneficial for them and that they experienced less discomfort during photic stimulation after the sessions. There were no side effects except transient skin rash in one patient, only. CONCLUSIONS In our sham controlled tDCS study with both cathodal and anodal stimulation, our data showed that there was no significant change in SWI during IPS, despite subjective well-being. tDCS' modulatory effect does not seem to act in the acute phase on EEG parameters after photic stimulation.
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Affiliation(s)
- Tülay Yılmaz Erol
- Departments of Neurology and Clinical Neurophysiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
| | - İrem İlgezdi Kaya
- Departments of Neurology and Clinical Neurophysiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
| | - Emel Ur Özçelik
- Department of Neurology, University of Health Sciences, Kanuni Sultan Süleyman Education and Research Hospital, Istanbul, Turkey.
| | - Serkan Aksu
- Department of Physiology, Faculty of Medicine, Muğla Sıtkı Koçman University, Muğla, Turkey.
| | - Nermin Görkem Şirin
- Departments of Neurology and Clinical Neurophysiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
| | - Nerses Bebek
- Departments of Neurology and Clinical Neurophysiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
| | - Adnan Kurt
- Department of Physiology, School of Medicine, Koç University, Istanbul, Turkey.
| | - Sacit Karamürsel
- Department of Physiology, School of Medicine, Koç University, Istanbul, Turkey.
| | - Betül Baykan
- Departments of Neurology and Clinical Neurophysiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey; Department of Neurology, EMAR Medical Center, Istanbul, Turkey.
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Richardson RJ, Petrou S, Bryson A. Established and emerging GABA A receptor pharmacotherapy for epilepsy. Front Pharmacol 2024; 15:1341472. [PMID: 38449810 PMCID: PMC10915249 DOI: 10.3389/fphar.2024.1341472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/07/2024] [Indexed: 03/08/2024] Open
Abstract
Drugs that modulate the GABAA receptor are widely used in clinical practice for both the long-term management of epilepsy and emergency seizure control. In addition to older medications that have well-defined roles for the treatment of epilepsy, recent discoveries into the structure and function of the GABAA receptor have led to the development of newer compounds designed to maximise therapeutic benefit whilst minimising adverse effects, and whose position within the epilepsy pharmacologic armamentarium is still emerging. Drugs that modulate the GABAA receptor will remain a cornerstone of epilepsy management for the foreseeable future and, in this article, we provide an overview of the mechanisms and clinical efficacy of both established and emerging pharmacotherapies.
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Affiliation(s)
- Robert J. Richardson
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia
- Department of Neurology, Austin Health, Heidelberg, VIC, Australia
| | - Steven Petrou
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia
- Praxis Precision Medicines, Boston, MA, United States
| | - Alexander Bryson
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia
- Department of Neurology, Austin Health, Heidelberg, VIC, Australia
- Department of Neurology, Eastern Health, Melbourne, VIC, Australia
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Becker DA, Wheless JW, Sirven J, Tatum WO, Rabinowicz AL, Carrazana E. Treatment of Seizure Clusters in Epilepsy: A Narrative Review on Rescue Therapies. Neurol Ther 2023; 12:1439-1455. [PMID: 37341903 PMCID: PMC10444935 DOI: 10.1007/s40120-023-00515-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 06/02/2023] [Indexed: 06/22/2023] Open
Abstract
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.
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Affiliation(s)
- Danielle A Becker
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA.
| | - James W Wheless
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Joseph Sirven
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | | | | | - Enrique Carrazana
- Neurelis, Inc., San Diego, CA, USA
- John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
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Perucca E, White HS, Bialer M. New GABA-Targeting Therapies for the Treatment of Seizures and Epilepsy: II. Treatments in Clinical Development. CNS Drugs 2023; 37:781-795. [PMID: 37603261 PMCID: PMC10501930 DOI: 10.1007/s40263-023-01025-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2023] [Indexed: 08/22/2023]
Abstract
The inhibitory neurotransmitter γ-aminobutyric acid (GABA) plays an important role in the modulation of neuronal excitability, and a disruption of GABAergic transmission contributes to the pathogenesis of some seizure disorders. Although many currently available antiseizure medications do act at least in part by potentiating GABAergic transmission, there is an opportunity for further research aimed at developing more innovative GABA-targeting therapies. The present article summarises available evidence on a number of such treatments in clinical development. These can be broadly divided into three groups. The first group consists of positive allosteric modulators of GABAA receptors and includes Staccato® alprazolam (an already marketed benzodiazepine being repurposed in epilepsy as a potential rescue inhalation treatment for prolonged and repetitive seizures), the α2/3/5 subtype-selective agents darigabat and ENX-101, and the orally active neurosteroids ETX155 and LPCN 2101. A second group comprises two drugs already marketed for non-neurological indications, which could be repurposed as treatments for seizure disorders. These include bumetanide, a diuretic agent that has undergone clinical trials in phenobarbital-resistant neonatal seizures and for which the rationale for further development in this indication is under debate, and ivermectin, an antiparasitic drug currently investigated in a randomised double-blind trial in focal epilepsy. The last group comprises a series of highly innovative therapies, namely GABAergic interneurons (NRTX-001) delivered via stereotactic cerebral implantation as a treatment for mesial temporal lobe epilepsy, an antisense oligonucleotide (STK-001) aimed at upregulating NaV1.1 currents and restoring the function of GABAergic interneurons, currently tested in a trial in patients with Dravet syndrome, and an adenoviral vector-based gene therapy (ETX-101) scheduled for investigation in Dravet syndrome. Another agent, a subcutaneously administered neuroactive peptide (NRP2945) that reportedly upregulates the expression of GABAA receptor α and β subunits is being investigated, with Lennox-Gastaut syndrome and other epilepsies as proposed indications. The diversity of the current pipeline underscores a strong interest in the GABA system as a target for new treatment development in epilepsy. To date, limited clinical data are available for these investigational treatments and further studies are required to assess their potential value in addressing unmet needs in epilepsy management.
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Affiliation(s)
- Emilio Perucca
- Department of Medicine (Austin Health), Melbourne Brain Centre, The University of Melbourne, 245 Burgundy Street, Melbourne, VIC, 3084, Australia.
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia.
| | - H Steve White
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Meir Bialer
- Faculty of Medicine, Institute of Drug Research, School of Pharmacy, The Hebrew University of Jerusalem, Jerusalem, Israel
- David R. Bloom Center for Pharmacy, The Hebrew University of Jerusalem, Jerusalem, Israel
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Krauss GL, Elizebath R, Mwendaweli N. Seizure Rescue Therapies: Comparing Approved and Commonly Used Benzodiazepine Formulations. Neurotherapeutics 2023; 20:758-766. [PMID: 36928590 PMCID: PMC10275833 DOI: 10.1007/s13311-023-01359-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2023] [Indexed: 03/18/2023] Open
Abstract
Acute seizure therapies given out of the hospital are important for interrupting acute repetitive and prolonged seizures and preventing hospitalization. These vary in their administration routes, indications for children and adults, pharmacologic profiles, and efficacy. We reviewed and compared the uses of current formulations available to treat acute seizures, including newly released intranasal (IN) benzodiazepines and older formulations which are widely used for interrupting seizures.
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Affiliation(s)
- Gregory L Krauss
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
| | - Reena Elizebath
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Naluca Mwendaweli
- Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia
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Gao C, Pielas M, Jiao F, Mei D, Wang X, Kotulska K, Jozwiak S. Epilepsy in Dravet Syndrome—Current and Future Therapeutic Opportunities. J Clin Med 2023; 12:jcm12072532. [PMID: 37048615 PMCID: PMC10094968 DOI: 10.3390/jcm12072532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/17/2023] [Accepted: 03/23/2023] [Indexed: 03/30/2023] Open
Abstract
Dravet Syndrome (DS) is a developmental epileptic encephalopathy characterized by drug-resistant seizures and other clinical features, including intellectual disability and behavioral, sleep, and gait problems. The pathogenesis is strongly connected to voltage-gated sodium channel dysfunction. The current consensus of seizure management in DS consists of a combination of conventional and recently approved drugs such as stiripentol, cannabidiol, and fenfluramine. Despite promising results in randomized clinical trials and extension studies, the prognosis of the developmental outcomes of patients with DS remains unfavorable. The article summarizes recent changes in the therapeutic approach to DS and discusses ongoing clinical research directions. Serotonergic agents under investigation show promising results and may replace less DS-specific medicines. The use of antisense nucleotides and gene therapy is focused not only on symptom relief but primarily addresses the underlying cause of the syndrome. Novel compounds, after expected safe and successful implementation in clinical practice, will open a new era for patients with DS. The main goal of causative treatment is to modify the natural course of the disease and provide the best neurodevelopmental outcome with minimum neurological deficit.
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Rescue Medications for Acute Repetitive Seizures. Curr Treat Options Neurol 2023. [DOI: 10.1007/s11940-023-00746-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
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French J, Biton V, Dave H, Detyniecki K, Gelfand MA, Gong H, Liow K, O'Brien TJ, Sadek A, DiVentura B, Reich B, Isojarvi J. A randomized phase 2b efficacy study in patients with seizure episodes with a predictable pattern using Staccato® alprazolam for rapid seizure termination. Epilepsia 2023; 64:374-385. [PMID: 36268811 PMCID: PMC10107237 DOI: 10.1111/epi.17441] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 10/17/2022] [Accepted: 10/19/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Alprazolam administered via the Staccato® breath-actuated device is delivered into the deep lung for rapid systemic exposure and is a potential therapy for rapid epileptic seizure termination (REST). We conducted an inpatient study (ENGAGE-E-001 [NCT03478982]) in patients with stereotypic seizure episodes with prolonged or repetitive seizures to determine whether Staccato alprazolam rapidly terminates seizures in a small observed population after administration under direct supervision. METHODS Adult patients with established diagnosis of focal and/or generalized epilepsy with a documented history of seizure episodes with a predictable pattern were enrolled. They were randomized 1:1:1 to double-blind treatment of a single seizure event with one dose of Staccato alprazolam 1.0 mg or 2.0 mg, or Staccato placebo in an inpatient unit. The primary end point of the study was the proportion of responders in each treatment group achieving seizure activity cessation within 2 min after administration of study drug and no recurrence of seizure activity within 2 h. RESULTS A total of 273 patients were screened, and 116 randomized patients received treatment with the study drug in the double-blind part. The proportion of treated patients who were responders was 65.8% for each of Staccato alprazolam 1.0 mg (n = 38; p = .0392) and 2.0 mg (n = 38; p = .0392), compared with 42.5% for Staccato placebo (n = 40). Staccato alprazolam was well tolerated when administered as a single dose of 1.0 or 2.0 mg: cough and somnolence were the most common adverse events (AEs) (both 14.5%), followed by dysgeusia (13.2%). AEs were mostly mild or moderate in intensity; there were no treatment-related serious AEs. SIGNIFICANCE Both 1.0 mg and 2.0 mg doses of Staccato alprazolam demonstrated efficacy in rapidly terminating seizures in an inpatient setting and were well tolerated. The next step is a Phase 3 confirmatory study to demonstrate efficacy and safety of Staccato alprazolam for rapid cessation of seizures in an outpatient setting.
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Affiliation(s)
| | - Victor Biton
- Arkansas Epilepsy Program, Little Rock, Arkansas, USA
| | - Hina Dave
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | | | - Hui Gong
- Rancho Los Amigos National Rehabilitation Center, Downey, California, USA
| | - Kore Liow
- Hawaii Pacific Neuroscience, Honolulu, Hawaii, USA
| | | | - Ahmed Sadek
- Research Institute of Orlando, LLC, Orlando, Florida, USA
| | - Bree DiVentura
- The Epilepsy Study Consortium, Woodbury, New Jersey, USA
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Kasteleijn-Nolst Trenite D, Reed RC. Brivaracetam or levetiracetam in status epilepticus?: Lessons from the photosensitivity model. Epilepsy Behav 2023; 138:109018. [PMID: 36528008 DOI: 10.1016/j.yebeh.2022.109018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/22/2022] [Indexed: 12/23/2022]
Abstract
First, a short history is given of the use of the EEG as a biomarker of efficacy in anti-seizure medication (ASM) development. The generalized epileptiform EEG response to Intermittent Photic Stimulation (IPS), the photoparoxysmal EEG response or PPR, in particular, is a reliable reproducible measure since the 1950s. Over time, a "Photosensitivity Model", testing within the same patients the impact of potential new oral ASMs, along with dose-ranging data, on PPRs, has been developed successfully. The classical Photosensitivity Model consists of IPS and blood sampling for ASM measurement performed hourly between 8 AM and 5 PM over three consecutive days. This single-blind, placebo-controlled, pharmacokinetic-pharmacodynamic (PK/PD) Model is now commonly utilized as a Proof-of-Concept Phase 2a trial. For Generalized Tonic-Clonic Status Epilepticus (GTCSE), it is especially relevant to know the time for CNS entry and effect minutes after i.v. ASM treatment, since "time is brain". We, therefore, adapted successfully the Model to a time-efficient Model with the determination of photosensitivity ranges in minutes after equivalent doses of iv brivaracetam (BRV) and levetiracetam (LEV). This modified design allows one to monitor the time to CNS effect (i.e., PPR elimination) of a quickly-acting FDA-approved ASM given i.v., a crucial element in status epilepticus treatment. This paper was presented at the 8th London-Innsbruck Colloqium on Status Epilepticus and Acute Seizures held in September 2022.
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Affiliation(s)
- Dorothee Kasteleijn-Nolst Trenite
- Department of Neurosurgery and Epilepsy, University Medical Center Utrecht, Utrecht, The Netherlands; Nesmos Department, Faculty of Medicine and Psychology, Sapienza University, Roma, Italy.
| | - Ronald C Reed
- Dept. of Clinical Pharmacy, School of Pharmacy, West Virginia University, 1124 Health Science Center North, Morgantown, WV 26506-9520, United States.
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Chung S, Peters JM, Detyniecki K, Tatum W, Rabinowicz AL, Carrazana E. The nose has it: Opportunities and challenges for intranasal drug administration for neurologic conditions including seizure clusters. Epilepsy Behav Rep 2022; 21:100581. [PMID: 36636458 PMCID: PMC9829802 DOI: 10.1016/j.ebr.2022.100581] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/20/2022] [Accepted: 12/27/2022] [Indexed: 12/29/2022] Open
Abstract
Nasal administration of treatments for neurologic conditions, including rescue therapies to treat seizure clusters among people with epilepsy, represents a meaningful advance in patient care. Nasal anatomy and physiology underpin the multiple advantages of nasal administration but also present challenges that must be addressed in any successful nasal formulation. Nasal cavity anatomy is complex, with a modest surface area for absorption that limits the dose volume of an intranasal formulation. The mucociliary clearance mechanism and natural barriers of the nasal epithelia must be overcome for adequate absorption. An extensive vasculature and the presence of olfactory nerves in the nasal cavity enable both systemic and direct-to-brain delivery of drugs targeting the central nervous system. Two intranasal benzodiazepine rescue therapies have been approved by the US Food and Drug Administration for seizure-cluster treatment, in addition to the traditional rectal formulation. Nasal sprays are easy to use and offer the potential for quick and consistent bioavailability. This review aims to increase the clinician's understanding of nasal anatomy and physiology and of the formulation of intranasal rescue therapies and to facilitate patient education and incorporate intranasal rescue therapies for seizure clusters (also known as acute repetitive seizures) into their seizure action plans.
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Affiliation(s)
- Steve Chung
- Banner University Medical Center, University of Arizona, 475 N. 5th St., Phoenix, AZ 85004, United States,Corresponding author.
| | - Jurriaan M. Peters
- Boston Children’s Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115, United States
| | - Kamil Detyniecki
- Miller School of Medicine, University of Miami, 1600 NW 10th Ave #1140, Miami, FL 33136, United States
| | - William Tatum
- Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL 32224, United States
| | | | - Enrique Carrazana
- Neurelis, Inc., 3430 Carmel Mountain Rd, San Diego, CA 92121, United States,John A. Burns School of Medicine, University of Hawaii, 651 Ilalo St, Honolulu, HI 96813, United States
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14
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Jafarpour S, Fong MWK, Detyniecki K, Khan A, Jackson-Shaheed E, Wang X, Lewis S, Benjamin R, Gaínza-Lein M, O'Bryan J, Hirsch LJ, Loddenkemper T. Prevalence and Predictors of Seizure Clusters in Pediatric Patients With Epilepsy: The Harvard-Yale Pediatric Seizure Cluster Study. Pediatr Neurol 2022; 137:22-29. [PMID: 36208614 DOI: 10.1016/j.pediatrneurol.2022.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 08/30/2022] [Indexed: 10/14/2022]
Abstract
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.
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Affiliation(s)
- Saba Jafarpour
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Neurology, Children's Hospital of Los Angeles, Los Angeles, California
| | - Michael W K Fong
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut; TY Nelson Department of Neurology, The Children's Hospital at Westmead, Sydney, Australia; Westmead Comprehensive Epilepsy Unit, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Kamil Detyniecki
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut; Comprehensive Epilepsy Center, Department of Neurology, University of Miami, Miami, Florida
| | - Ambar Khan
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut; Larkin Community Hospital, South Miami, Florida
| | - Ebony Jackson-Shaheed
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut
| | - Xiaofan Wang
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Samuel Lewis
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Robert Benjamin
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Marina Gaínza-Lein
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Instituto dr Pediatria, Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Jane O'Bryan
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut
| | - Lawrence J Hirsch
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
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15
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Kotloski RJ, Gidal BE. Rescue Treatments for Seizure Clusters. Neurol Clin 2022; 40:927-937. [DOI: 10.1016/j.ncl.2022.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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16
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Gidal B, Detyniecki K. Rescue therapies for seizure clusters: Pharmacology and target of treatments. Epilepsia 2022; 63 Suppl 1:S34-S44. [PMID: 35999174 PMCID: PMC9543841 DOI: 10.1111/epi.17341] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/08/2022] [Accepted: 06/08/2022] [Indexed: 12/03/2022]
Abstract
The primary goal of treatment for seizure clusters is cessation of the cluster to avoid progression to more severe conditions, such as prolonged seizures and status epilepticus. Rescue therapies are key components of treatment plans for patients with seizure clusters. Three rescue therapies are approved in the United States for the treatment of seizure clusters: diazepam rectal gel, midazolam nasal spray, and diazepam nasal spray. This review characterizes the pharmacological function of rescue therapies for seizure clusters, as well as describing γ‐aminobutyric acid A (GABAA) receptor functions. GABAA receptors are heteropentamers, consisting primarily of α1‐6, β1‐3, γ2, and δ subunits in the central nervous system. These subunits can traffic to and from the membrane to regulate membrane potential. Benzodiazepines, such as diazepam and midazolam, are positive allosteric modulators of GABAA receptors, the activation of which leads to an increase in intracellular chloride, hyperpolarization of the cell membrane, and a reduction in excitation. GABAA receptor subunit mutations, dysregulation of trafficking, and degradation are associated with epilepsy. Although benzodiazepines are effective GABAA receptor modulators, individual formulations have unique profiles in practice. Diazepam rectal gel is an effective rescue therapy for seizure clusters; however, adults and adolescents may have social reservations regarding its administration. Intranasal delivery of midazolam or diazepam is a promising alternative to rectal administration because these formulations offer easy, socially acceptable administration and exhibit a rapid onset. Off‐label benzodiazepines, such as orally disintegrating lorazepam and intranasal use of an intravenous formulation of midazolam via nasal atomizer, are less well characterized regarding bioavailability and tolerability compared with approved agents.
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Affiliation(s)
- Barry Gidal
- School of Pharmacy, University of Wisconsin-Madison, Madison, Wisconsin, United States
| | - Kamil Detyniecki
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, United States
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17
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Blond BN, Hirsch LJ. Updated review of rescue treatments for seizure clusters and prolonged seizures. Expert Rev Neurother 2022; 22:567-577. [PMID: 35862983 DOI: 10.1080/14737175.2022.2105207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Although the treatment of epilepsy primarily focuses on prevention, recurrent seizures are unfortunately an ongoing reality, particularly in people with epilepsy who live with chronic refractory seizures. Rescue medications are agents which can be administered in urgent/emergent seizure episodes such as seizure clusters or prolonged seizures with the goal of terminating seizure activity, preventing morbidity, and decreasing the risk of further seizures. AREAS COVERED This review first discusses clinical opportunities for rescue medications, with particular attention focused on seizure clusters and prolonged seizures, including their epidemiology, risk factors, and associated morbidity. Current rescue medications, their indications, efficacy, and adverse effects are discussed. We then discuss rescue medications and formulations which are currently under development, concentrating on practical aspects relevant for clinical care. EXPERT OPINION Rescue medications should be considered for all people with epilepsy with ongoing seizures. Recent rescue medications including intranasal formulations provide considerable advantages. New rescue medications are being developed which may expand opportunities for effective treatment. In the future, combining rescue medications with seizure detection and seizure prediction technologies should further expand opportunities for use and should reduce the morbidity of seizures and provide increased comfort, control, and quality of life for people living with epilepsy.
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Affiliation(s)
- Benjamin N Blond
- Department of Neurology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY
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18
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Tai W, Kwok PCL. Recent advances in drug delivery to the central nervous system by inhalation. Expert Opin Drug Deliv 2022; 19:539-558. [PMID: 35532357 DOI: 10.1080/17425247.2022.2074975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Drugs need to enter the systemic circulation efficiently before they can cross the blood-brain barrier and reach the central nervous system. Although the respiratory tract is not a common route of administration for delivering drugs to the central nervous system, it has attracted increasing interest in recent years for this purpose. AREAS COVERED In this article, we compare pulmonary delivery to three other common routes (parenteral, oral, and intranasal) for delivering drugs to the central nervous system, followed by summarising the devices used to aerosolise neurological drugs. Recent studies delivering drugs for different neurological disorders via inhalation are then discussed to illustrate the strengths of pulmonary delivery. EXPERT OPINION Recent studies provide strong evidence and rationale to support inhaling neurological drugs. Since inhalation can achieve improved pharmacokinetics and rapid onset of action for multiple drugs, it is a non-invasive and efficient method to deliver drugs to the central nervous system. Future research should focus on delivering other small and macro-molecules via the lungs for different neurological conditions.
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Affiliation(s)
- Waiting Tai
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, New South Wales 2006, Australia
| | - Philip Chi Lip Kwok
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, New South Wales 2006, Australia
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19
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Abstract
PURPOSE OF REVIEW The purpose of this review is to provide a succinct evaluation of the current rescue medications and action plans available to our patients with seizure clusters in the outpatient setting. RECENT FINDINGS The main themes of the recent findings are that rescue medications and seizure action plans (SAPs) are underutilized, particularly in the adult population. The safety and efficacy of intranasal midazolam and intranasal diazepam is comparable with rectal diazepam for the treatment of seizure clusters. Additionally, this intranasal formulation has the benefit of a more socially acceptable route of administration and ease of use. SUMMARY The implication of these findings is a greater variety and awareness in the rescue medications available to our patients suffering from seizure clusters.
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Affiliation(s)
- Sonali Sharma
- University of Miami, Miller School of Medicine, Miami, Florida, USA
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20
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Fisher RS, Acharya JN, Baumer FM, French JA, Parisi P, Solodar JH, Szaflarski JP, Thio LL, Tolchin B, Wilkins AJ, Kasteleijn-Nolst Trenité D. Visually sensitive seizures: An updated review by the Epilepsy Foundation. Epilepsia 2022; 63:739-768. [PMID: 35132632 DOI: 10.1111/epi.17175] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/10/2022] [Accepted: 01/12/2022] [Indexed: 12/19/2022]
Abstract
Light flashes, patterns, or color changes can provoke seizures in up to 1 in 4000 persons. Prevalence may be higher because of selection bias. The Epilepsy Foundation reviewed light-induced seizures in 2005. Since then, images on social media, virtual reality, three-dimensional (3D) movies, and the Internet have proliferated. Hundreds of studies have explored the mechanisms and presentations of photosensitive seizures, justifying an updated review. This literature summary derives from a nonsystematic literature review via PubMed using the terms "photosensitive" and "epilepsy." The photoparoxysmal response (PPR) is an electroencephalography (EEG) phenomenon, and photosensitive seizures (PS) are seizures provoked by visual stimulation. Photosensitivity is more common in the young and in specific forms of generalized epilepsy. PS can coexist with spontaneous seizures. PS are hereditable and linked to recently identified genes. Brain imaging usually is normal, but special studies imaging white matter tracts demonstrate abnormal connectivity. Occipital cortex and connected regions are hyperexcitable in subjects with light-provoked seizures. Mechanisms remain unclear. Video games, social media clips, occasional movies, and natural stimuli can provoke PS. Virtual reality and 3D images so far appear benign unless they contain specific provocative content, for example, flashes. Images with flashes brighter than 20 candelas/m2 at 3-60 (particularly 15-20) Hz occupying at least 10 to 25% of the visual field are a risk, as are red color flashes or oscillating stripes. Equipment to assay for these characteristics is probably underutilized. Prevention of seizures includes avoiding provocative stimuli, covering one eye, wearing dark glasses, sitting at least two meters from screens, reducing contrast, and taking certain antiseizure drugs. Measurement of PPR suppression in a photosensitivity model can screen putative antiseizure drugs. Some countries regulate media to reduce risk. Visually-induced seizures remain significant public health hazards so they warrant ongoing scientific and regulatory efforts and public education.
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Affiliation(s)
- Robert S Fisher
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Jayant N Acharya
- Department of Neurology, Penn State Health, Hershey, Pennsylvania, USA
| | - Fiona Mitchell Baumer
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Jacqueline A French
- NYU Comprehensive Epilepsy Center, Epilepsy Foundation, New York, New York, USA
| | - Pasquale Parisi
- Department of Neuroscience, Mental Health, and Sensory Organs, Sapienza University, Rome, Italy
| | - Jessica H Solodar
- American Medical Writers Association-New England Chapter, Boston, Massachusetts, USA
| | - Jerzy P Szaflarski
- Department of Neurology, Neurobiology and Neurosurgery, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Liu Lin Thio
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Benjamin Tolchin
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
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21
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Benzodiazepines in the Management of Seizures and Status Epilepticus: A Review of Routes of Delivery, Pharmacokinetics, Efficacy, and Tolerability. CNS Drugs 2022; 36:951-975. [PMID: 35971024 PMCID: PMC9477921 DOI: 10.1007/s40263-022-00940-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/11/2022] [Indexed: 02/05/2023]
Abstract
Status epilepticus (SE) is an acute, life-threatening medical condition that requires immediate, effective therapy. Therefore, the acute care of prolonged seizures and SE is a constant challenge for healthcare professionals, in both the pre-hospital and the in-hospital settings. Benzodiazepines (BZDs) are the first-line treatment for SE worldwide due to their efficacy, tolerability, and rapid onset of action. Although all BZDs act as allosteric modulators at the inhibitory gamma-aminobutyric acid (GABA)A receptor, the individual agents have different efficacy profiles and pharmacokinetic and pharmacodynamic properties, some of which differ significantly. The conventional BZDs clonazepam, diazepam, lorazepam and midazolam differ mainly in their durations of action and available routes of administration. In addition to the common intravenous, intramuscular and rectal administrations that have long been established in the acute treatment of SE, other administration routes for BZDs-such as intranasal administration-have been developed in recent years, with some preparations already commercially available. Most recently, the intrapulmonary administration of BZDs via an inhaler has been investigated. This narrative review provides an overview of the current knowledge on the efficacy and tolerability of different BZDs, with a focus on different routes of administration and therapeutic specificities for different patient groups, and offers an outlook on potential future drug developments for the treatment of prolonged seizures and SE.
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22
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Boada CM, Grossman SN, Grzeskowiak CL, Dumanis S, French JA. Proceedings of the 2020 Epilepsy Foundation Pipeline Conference: Emerging Drugs and Devices. Epilepsy Behav 2021; 125:108364. [PMID: 34731723 DOI: 10.1016/j.yebeh.2021.108364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 09/25/2021] [Indexed: 11/17/2022]
Abstract
From August 27-28, 2020 the Epilepsy Foundation hosted the Pipeline Conference, exploring emerging issues related to antiepileptic drug and device development. The conference featured epilepsy therapeutic companies and academic laboratories developing drugs for focal epilepsies, innovations for rare and ultra-rare diseases, and devices both in clinical trials and approved for use. In this paper, we outline the virtual presentations by the authors, including novel data from their development pipeline.
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Affiliation(s)
- Christina M Boada
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA.
| | - Scott N Grossman
- Department of Neurology, New York University Langone Health, New York, NY, USA
| | | | | | - Jacqueline A French
- Department of Neurology, New York University Langone Health, New York, NY, USA
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23
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Samanta D. Rescue therapies for seizure emergencies: current and future landscape. Neurol Sci 2021; 42:4017-4027. [PMID: 34269935 PMCID: PMC8448953 DOI: 10.1007/s10072-021-05468-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/05/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Seizure emergencies-status epilepticus and seizure clusters-require rapid evaluation and treatment. Several consensus-based guidelines support a prompt use of intravenous benzodiazepines as the first-line therapy in seizure emergencies. However, most seizure emergencies start outside the hospital settings. Until recently, approved prehospital rescue therapies were limited to rectal diazepam and buccal midazolam (Europe only). METHODS The author provides a narrative review of rescue therapies for seizure emergencies based on a comprehensive literature review (PubMed and OvidSP vendors with appropriate keywords to incorporate recent evidence) to highlight the changing landscape of seizure recue therapies. RESULTS A commercial version of intranasal midazolam was approved by the FDA in 2019 for 12 ≥ years old with seizure clusters. In 2020, the FDA also approved a proprietary vitamin E solution-based diazepam nose spray to abort seizure clusters in ≥ 6 years old subjects. Other than these two new options, the author discussed two previously approved therapies: rectal diazepam and buccal midazolam. The review also includes the use of intramuscular diazepam and midazolam, clonazepam wafer, sublingual and intranasal lorazepam in seizure emergencies. Besides the availability of new therapies from successful trials in controlled settings, the real-world challenges of using rescue medicines in community settings are slowly emerging. DISCUSSION With multiple options, a more robust and updated cost-effective analysis of different rescue medicines needs to be performed using effectiveness data from the literature and cost data from publicly available market prices. Further research is also ongoing to develop alternative non-intravenous treatment options for outpatient settings. Lastly, several other non-benzodiazepine drugs, such as allopregnanolone, propofol, and brivaracetam, are also currently under development for seizure emergencies.
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Affiliation(s)
- Debopam Samanta
- Child Neurology Section, Department of Pediatrics, University of Arkansas for Medical Sciences, 1 Children's Way, Little Rock, AR, 72202, USA.
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Chung S, Szaflarski JP, Choi EJ, Wilson JC, Kharawala S, Kaur G, Hirsch LJ. A systematic review of seizure clusters: Prevalence, risk factors, burden of disease and treatment patterns. Epilepsy Res 2021; 177:106748. [PMID: 34521043 DOI: 10.1016/j.eplepsyres.2021.106748] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 08/05/2021] [Accepted: 08/24/2021] [Indexed: 11/17/2022]
Abstract
Seizure clusters (SCs) are episodes of consecutive seizures that occur within a short period. The treatment patterns of rescue medications (RMs), as well as the burden of SCs, have not been assessed. A systematic literature search on Embase.com (in PubMed and Embase), supplemented with keyword-based and bibliographic searches, identified 44 articles for disease burden, three treatment guidelines, and three articles for treatment patterns. Common SC definitions were ≥3 seizures/24 h, ≥2/24 h and ≥2/6 h. The rate of SCs in prospective studies ranged from 21.7 %-42.5 %. The frequency of status epilepticus (SE) was higher in SC patients. SCs were associated with higher seizure frequency, higher risk of treatment resistance, and lower likelihood of seizure remission. Quality of life (QoL) was lower in children with SCs than in those with isolated seizures. Seizure-related hospitalization was more common in SC than non-SC patients. SCs adversely affected the productivity of patients and their caregivers. In outpatients with SCs, RMs were prescribed to 24.6 %-89.6 % and utilized by 15.6 %-44.5 %, with rates being higher in children. Key reasons for RM under-utilization were lack of seizure action plans, poor physician-patient communication, and concerns with administration route. In conclusion, SCs are associated with a higher risk of SE, treatment resistance, and low rate of seizure remission. They adversely affect patient and caregiver QoL and work productivity. However, RMs are under-prescribed, and there is an urgent need to improve recognition of SCs, improve use of seizure action plans, and remove barriers to RM use.
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Affiliation(s)
- Steve Chung
- Banner University Medical Center, University of Arizona, Phoenix, AZ, USA.
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25
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Abstract
Acute repetitive seizures, also called seizure clusters, are common phenomena in patients with epilepsy. They are a burden on patients and their caregivers and may be very disruptive to the patients' lives. They may progress to prolonged seizures or status epilepticus if they are not aborted as soon as possible. However, their definition, recognition, and classification still suffer from a lack of consensus among healthcare professionals in the field. This review aims to shed light on various aspects of seizure clusters with particular attention to their treatments.
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Affiliation(s)
- Boulenouar Mesraoua
- Hamad Medical Corporation, Doha, Qatar.,Weill Cornell Medical College, Doha, Qatar
| | - Bassel Abou-Khalil
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Gayane Melikyan
- Hamad Medical Corporation, Doha, Qatar.,Weill Cornell Medical College, Doha, Qatar
| | - Hassan Al Hail
- Hamad Medical Corporation, Doha, Qatar.,Weill Cornell Medical College, Doha, Qatar
| | - Ali A Asadi-Pooya
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Jefferson Comprehensive Epilepsy Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
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Abstract
Context Refractory status epilepticus (RSE) and super-refractory status epilepticus (SRSE) are neurological emergencies with considerable mortality and morbidity. In this paper, we provide an overview of causes, evaluation, treatment, and consequences of RSE and SRSE, reflecting the lack of high-quality evidence to inform therapeutic approach. Sources This is a narrative review based on personal practice and experience. Nevertheless, we searched MEDLINE (using PubMed and OvidSP vendors) and Cochrane central register of controlled trials, using appropriate keywords to incorporate recent evidence. Results Refractory status epilepticus is commonly defined as an acute convulsive seizure that fails to respond to two or more anti-seizure medications including at least one nonbenzodiazepine drug. Super-refractory status epilepticus is a status epilepticus that continues for ≥24 hours despite anesthetic treatment, or recurs on an attempted wean of the anesthetic regimen. Both can occur in patients known to have epilepsy or de novo, with increasing recognition of autoimmune and genetic causes. Electroencephalography monitoring is essential to monitor treatment response in refractory/super-refractory status epilepticus, and to diagnose non-convulsive status epilepticus. The mainstay of treatment for these disorders includes anesthetic infusions, primarily midazolam, ketamine, and pentobarbital. Dietary, immunological, and surgical treatments are viable in selected patients. Management is challenging due to multiple acute complications and long-term adverse consequences. Conclusions We have provided a synopsis of best practices for diagnosis and management of refractory/superrefractory status epilepticus and highlighted the lack of sufficient high-quality evidence to drive decision making, ending with a brief foray into avenues for future research.
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Affiliation(s)
- Debopam Samanta
- Child Neurology Division, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Lisa Garrity
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ravindra Arya
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; USA. Correspondence to: Dr Ravindra Arya, Division of Neurology, Cincinnati Children's Hospital Medical Center, MLC 2015, 3333 Burnet Avenue, Cincinnati, Ohio, 45229 USA.
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Wheless JW. A critical evaluation of midazolam nasal spray for the treatment of patients with seizure clusters. Expert Rev Neurother 2021; 21:1195-1205. [PMID: 33593228 DOI: 10.1080/14737175.2021.1890033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Patients with epilepsy may experience seizure clusters (SCs), which are considered a medical emergency requiring immediate treatment. Besides seizures and seizure-related injuries, patients with SCs experience impaired quality of life and have a greater need for healthcare resources. Midazolam nasal spray (MDZ-NS) was approved by the United States Food and Drug Administration (FDA) for the treatment of SCs in 2019, and was the first FDA-approved nasally administered formulation for treating SCs.Areas covered: This article provides a critical evaluation of MDZ-NS for the treatment of patients with SCs. It covers the chemistry, pharmacodynamic and pharmacokinetic properties of MDZ-NS, and safety, tolerability, and efficacy data from phase I and phase III trials. SC treatment guidelines in different countries and for alternative therapies are also discussed.Expert opinion: Midazolam is a well-established drug that is familiar to physicians. The newer MDZ-NS formulation offers the benefits of intranasal administration, which allows for outpatient treatment by caregivers and other non-healthcare professionals when an SC occurs, and may be particularly meaningful to patients with limited treatment options because other routes of administration are unsuitable. MDZ-NS is effective and patients are known to return to baseline alertness and psychomotor function within 240 minutes after administration.
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Affiliation(s)
- James W Wheless
- Le Bonheur Comprehensive Epilepsy Program & Neuroscience Institute, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Cloyd J, Haut S, Carrazana E, Rabinowicz AL. Overcoming the challenges of developing an intranasal diazepam rescue therapy for the treatment of seizure clusters. Epilepsia 2021; 62:846-856. [PMID: 33617690 PMCID: PMC8248041 DOI: 10.1111/epi.16847] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/29/2021] [Accepted: 01/29/2021] [Indexed: 01/19/2023]
Abstract
Seizure clusters must be treated quickly and effectively to prevent progression to prolonged seizures and status epilepticus. Rescue therapy for seizure clusters has focused on the use of benzodiazepines. Although intravenous benzodiazepine administration is the primary route in hospitals and emergency departments, seizure clusters typically occur in out‐of‐hospital settings, where a more portable product that can be easily administered by nonmedical caregivers is needed. Thus, other methods of administration have been examined, including rectal, intranasal, intramuscular, and buccal routes. Following US Food and Drug Administration (FDA) approval in 1997, rectal diazepam became the mainstay of out‐of‐hospital treatment for seizure clusters in the United States. However, social acceptability and consistent bioavailability present limitations. Intranasal formulations have potential advantages for rescue therapies, including ease of administration and faster onset of action. A midazolam nasal spray was approved by the FDA in 2019 for patients aged 12 years or older. In early 2020, the FDA approved a diazepam nasal spray for patients aged 6 years or older, which has a different formulation than the midazolam nasal product and enhances aspects of bioavailability. Benzodiazepines, including diazepam, present significant challenges in developing a suitable intranasal formulation. Diazepam nasal spray contains dodecyl maltoside (DDM) as an absorption enhancer and vitamin E to increase solubility in an easy‐to‐use portable device. In a Phase 1 study, absolute bioavailability of the diazepam nasal spray was 97% compared with intravenous diazepam. Subsequently, the nasal spray demonstrated less variability in bioavailability than rectal gel (percentage of geometric coefficient of variation of area under the curve = 42%–66% for diazepam nasal spray compared with 87%–172% for rectal gel). The diazepam nasal spray safety profile is consistent with that expected for rectal diazepam, with low rates of nasal discomfort (≤6%). To further improve the efficacy of rescue therapy, investigation of novel intranasal benzodiazepine formulations is underway.
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Affiliation(s)
- James Cloyd
- University of Minnesota College of Pharmacy, Minneapolis, Minnesota, USA
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29
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Seizure Rescue Medications for Out-Of-Hospital Use in Children. J Pediatr 2021; 229:19-25. [PMID: 33228949 DOI: 10.1016/j.jpeds.2020.10.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/16/2020] [Accepted: 10/20/2020] [Indexed: 11/23/2022]
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Asnis-Alibozek A, Detyniecki K. The unmet need for rapid epileptic seizure termination (REST). Epilepsy Behav Rep 2020; 15:100409. [PMID: 33490947 PMCID: PMC7804985 DOI: 10.1016/j.ebr.2020.100409] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/28/2020] [Accepted: 11/08/2020] [Indexed: 11/15/2022] Open
Abstract
Approximately 40% of epilepsy patients will continue to experience breakthrough seizures despite stable antiepileptic drug regimens. Rescue treatments have demonstrated efficacy and safety for select seizure emergencies. Outpatient administered intranasal and rectally delivered medications are regulatory approved for acute repetitive seizures (ARS), and injectable benzodiazepines are indicated for parenteral treatment of established status epilepticus. Despite these advances, no studies have been shown to abort an ongoing seizure following patient or caregiver home administration of therapy at the first clinical sign of seizure onset. Such treatment would require rapid systemic absorption without intravenous access, and evidence of seizure cessation within minutes of administration that is superior to placebo (eg, seizure self-regulation). Rapid epileptic seizure termination (REST) treatment may apply to multiple seizure emergencies beyond ARS, including focal or generalized seizures preceded by an aura, flurries of absence or myoclonic seizures, or prolonged focal and generalized seizures at high risk of progression to status epilepticus. Novel investigational drug delivery systems have demonstrated feasibility of intraictal delivery and seizure cessation by two minutes. Ongoing randomized trials of REST treatment for diverse seizure emergencies hold the potential to decrease bouts of mental and physical incapacitation in patients with drug-resistant epilepsy.
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Affiliation(s)
- Aviva Asnis-Alibozek
- University of Lynchburg, School of PA Medicine, Doctor of Medical Science Program (DMSc Candidate), Lynchburg, VA 24501, United States
| | - Kamil Detyniecki
- University of Miami Miller School of Medicine, Department of Neurology, Miami, FL 33136, United States
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Gidal B, Klein P, Hirsch LJ. Seizure clusters, rescue treatments, seizure action plans: Unmet needs and emerging formulations. Epilepsy Behav 2020; 112:107391. [PMID: 32898744 DOI: 10.1016/j.yebeh.2020.107391] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/29/2020] [Accepted: 07/30/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW The aim of the study was to provide an overview of the prevalence, risk factors, burden, and current and emerging pharmacologic treatments for seizure clusters in patients with epilepsy. RECENT FINDINGS Close to half of patients with active epilepsy experience seizure clusters, and the clinical, social, and financial burdens of seizure clusters are high. However, there is no widely accepted definition of seizure clusters; their prevalence is underappreciated, contingencies for addressing them (seizure action plans) are often lacking, and their effects are not well-studied. These issues have resulted in an insufficient number of investigations and approved medications for this condition. Novel formulations are in late-stage development to meet this unmet need.
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Affiliation(s)
- Barry Gidal
- University of Wisconsin-Madison, School of Pharmacy, Madison, WI, USA.
| | - Pavel Klein
- Mid-Atlantic Epilepsy and Sleep Center, Bethesda, MD, USA
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