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Rodríguez-Uranga JJ, Sánchez-Caro JM, Hariramani Ramchandani R. Treatment simplification to optimize cenobamate effectiveness and tolerability: A real-world retrospective study in Spain. Epilepsia Open 2024. [PMID: 38800945 DOI: 10.1002/epi4.12959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 04/16/2024] [Accepted: 04/29/2024] [Indexed: 05/29/2024] Open
Abstract
OBJECTIVE This study aimed to explore the impact of co-antiseizure medication (co-ASM) optimization on the effectiveness and tolerability of adjunctive cenobamate (CNB) in patients with drug-resistant epilepsy in a real-world setting. METHODS This unicentric, retrospective, observational study included adults with focal-onset seizures who had received ≥2 previous ASMs. The main effectiveness endpoints included responder rates and seizure frequency reduction at 3, 6, and 12-month visits. The number of co-ASMs and defined daily dose (DDD) were analyzed at every visit. Safety endpoints included adverse drug reactions (ADRs). RESULTS Thirty-four patients with a median epilepsy duration of 22 years and a median of 15.5 seizures/month were analyzed. The median number of prior ASMs was 12, and the mean number of co-ASMs was 2.9 (SD 1). There was a reduction in seizure frequency/month from baseline to the last visit (p < 0.0001). Between baseline and the end of the study, the mean number of co-ASMs in the per-protocol (PP) population was reduced from 2.9 to 1.6 (p < 0.0001), and DDD was reduced from 3.6 to 1.4 (p < 0.0001). Sodium channel blockers (carbamazepine and lacosamide) and GABAergic drugs (clobazam) were the agents with the most significant reductions in DDD after 12 months. The percentage of patients in the PP population with ≥3 co-ASMs was reduced from 61.8% at baseline to 14.3% at 12 months; 1 patient was receiving CNB as monotherapy at the last visit. At the last visit, 85.7% of the PP population were ≥50% responders, and 33.3% were seizure-free. The percentage of patients with ADRs in the PP population was 71.9% at 3 months and 52.3% at 12 months. SIGNIFICANCE Following rational polytherapy, optimization of co-ASM management during CNB treatment allowed high seizure freedom rates despite meaningful reductions in co-medication, while also achieving both good tolerability and patient satisfaction scores in a highly drug-resistant population. PLAIN LANGUAGE SUMMARY Many patients with epilepsy still have seizures, even after being treated with several different epilepsy drugs. In this study of 34 patients from a Spanish clinic, we show that the epilepsy drug cenobamate can reduce the number of seizures in these patients, even after many other epilepsy drugs have failed. We also show that patients treated with cenobamate can reduce the dose or even stop taking certain other epilepsy drugs. This allows them to simplify their treatment and reduce adverse effects while still keeping control of their epilepsy.
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Punia V, Klein P, Mihaylova T, Biton V, Samad O, Ngo LY, Kumar D, Malhotra M. Perampanel as monotherapy or first adjunctive therapy in pediatric and adult patients with epilepsy: the first United States-based phase IV open-label ELEVATE study. J Neurol 2024:10.1007/s00415-024-12399-w. [PMID: 38730096 DOI: 10.1007/s00415-024-12399-w] [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: 01/24/2024] [Revised: 04/23/2024] [Accepted: 04/24/2024] [Indexed: 05/12/2024]
Abstract
ELEVATE (Study 410; NCT03288129) is the first prospective, multicenter, open-label, Phase IV study of perampanel as monotherapy or first adjunctive therapy in patients aged ≥ 4 years with focal-onset seizures or generalized tonic-clonic seizures in the United States. The study included Screening, Titration (≤ 13 weeks), Maintenance (39 weeks), and Follow-up (4 weeks) Periods. During Titration, perampanel was initiated at 2 mg/day and up-titrated to 4 mg/day at Week 3. Depending on response and tolerability, optional up-titrations to a maximum of 12 mg/day occurred. The primary endpoint was retention rate; additional endpoints included seizure-freedom rate, 50% responder rate, and incidence of treatment-emergent adverse events (TEAEs). At baseline, 10 (18.5%) patients were assigned to the monotherapy group and 44 (81.5%) patients to the first adjunctive therapy group. However, due to the addition of an anti-seizure medication along with perampanel on the first day of treatment, one patient was excluded from the monotherapy subgroup analyses. The mean perampanel exposure duration was 39.8 weeks and 32 (59.3%) patients completed the study. Retention rate at 12 months (or study completion) was 63.0% (monotherapy, 77.8%; first adjunctive therapy, 59.1%). Seizure-freedom rate during the Maintenance Period was 32.7% (monotherapy, 44.4%; first adjunctive therapy, 29.5%) and the 50% responder rate was 78.7% (monotherapy, 85.7%; first adjunctive therapy, 76.9%). TEAEs and serious TEAEs were reported by 88.9% (n = 48/54) and 7.4% (n = 4/54) of patients, respectively. Overall, the efficacy and safety of perampanel as monotherapy or first adjunctive therapy support the use of perampanel as early-line treatment for epilepsy.
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Affiliation(s)
- Vineet Punia
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA.
| | - Pavel Klein
- Mid-Atlantic Epilepsy and Sleep Center, Bethesda, MD, USA
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Steinhoff BJ, Georgiou D, Dietmann D, Intravooth T. Cenobamate Plasma Levels in Patients with Epilepsy: Correlation with Efficacy and Tolerability? J Clin Med 2024; 13:2757. [PMID: 38792299 PMCID: PMC11122064 DOI: 10.3390/jcm13102757] [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: 04/02/2024] [Revised: 05/01/2024] [Accepted: 05/06/2024] [Indexed: 05/26/2024] Open
Abstract
Objective: Cenobamate is approved by the European Medicine Agency for the treatment of adult patients with epilepsy (PWEs) with ongoing focal-onset seizures despite appropriate treatment with at least two established antiseizure medications. Pivotal trials and post-marketing real-world observational studies suggest high efficacy with unusually high seizure-free rates. The authors sought to investigate the plasma levels of cenobamate under steady-state conditions in seizure-free versus non-responding PWEs, and in PWEs who experienced adverse events versus those who did not. Methods: Blood samples were collected from adult PWEs who were treated with adjunct cenobamate under steady-state conditions. Daily doses, concomitant medications, efficacy, and tolerability were assessed. The plasma cenobamate levels of seizure-free versus non-responding PWEs and between PWEs with and those without clinical adverse events were compared. Results: Samples from 101 PWEs were included. Thirty-six PWEs were seizure-free and 65 were non-responders. In 31 PWEs, adverse events were apparent, whereas in the remaining 70, no tolerability issues were reported. A linear correlation was found between the daily doses (range: 100 mg-400 mg) and the plasma levels (3.8 mg/L-54.6 mg/L). Neither the daily doses nor the plasma levels differed significantly between the investigated subgroups. The main reason for this result was that the individual therapeutic ranges varied widely: seizure freedom and adverse effects were observed alongside low doses and plasma levels in some PWEs. Conversely, there were examples of PWEs who did not respond or who reported no tolerability issues at high doses or plasma levels. Conclusions: To evaluate the individual therapeutic range and to better understand the influence of other drugs in cases where concomitant medications are used, the therapeutic drug monitoring of cenobamate may be useful. A general therapeutic range cannot be defined.
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Affiliation(s)
- Bernhard J. Steinhoff
- Kork Epilepsy Center, Kehl-Kork, 77694 Kehl, Germany; (D.G.); (D.D.); (T.I.)
- Medical Faculty, University of Freiburg, 79104 Freiburg im Breisgau, Germany
| | - Dimitra Georgiou
- Kork Epilepsy Center, Kehl-Kork, 77694 Kehl, Germany; (D.G.); (D.D.); (T.I.)
| | - Daniel Dietmann
- Kork Epilepsy Center, Kehl-Kork, 77694 Kehl, Germany; (D.G.); (D.D.); (T.I.)
| | - Tassanai Intravooth
- Kork Epilepsy Center, Kehl-Kork, 77694 Kehl, Germany; (D.G.); (D.D.); (T.I.)
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Vashi V, Laramy J, Kamin M, Ferrari L, Hand A. Relative Bioavailability of Cenobamate Administered as a Crushed Tablet, Either Orally or via Nasogastric Tube, versus an Intact Whole Tablet. J Clin Pharmacol 2024. [PMID: 38683027 DOI: 10.1002/jcph.2439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 03/19/2024] [Indexed: 05/01/2024]
Abstract
Cenobamate is approved for the treatment of focal seizures in adults and is currently available as an oral tablet. Alternative methods of drug administration are needed for patients who are unable to swallow whole intact tablets. This phase 1, open-label, randomized, single-dose, three-way crossover (3-period, 3-treatment, 6-sequence) study (NCT05572255), conducted in healthy volunteers, assessed the relative bioavailability of a crushed 200-mg cenobamate tablet administered orally or via nasogastric (NG) tube compared with an intact 200-mg tablet. Each treatment was separated by a 13-day washout period. Plasma samples for cenobamate concentration analysis were collected pre-dose and at multiple time points up to 264 h post-dose. Standard bioequivalence study criteria were applied to the relative bioavailability assessments. All 90% confidence intervals of test-to-reference geometric mean ratios for cenobamate pharmacokinetic parameters (Cmax, AUClast, and AUCinf) were within 85-110% (predefined limit, 80-125%), suggesting no difference in cenobamate exposures following administration of an intact tablet orally or a crushed tablet orally or via NG tube. All treatment-emergent adverse events (TEAEs) were classified as mild and resolved. There were no deaths or other serious AEs (SAEs), and no TEAEs led to discontinuation. Our results indicate that the administration of cenobamate as a crushed tablet taken orally or via an NG tube can provide additional flexibility when patients cannot swallow intact tablets. Based on the results of this study, cenobamate is now approved by FDA to be taken whole or the tablets can be crushed. The crushed tablet can be mixed with water and either administered by mouth as an oral suspension or administered via a nasogastric tube.
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Affiliation(s)
| | | | | | | | - Alan Hand
- Worldwide Clinical Trials, San Antonio, TX, USA
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Carreño M, Gil-Nagel A, Serratosa JM, Toledo M, Rodriguez-Uranga JJ, Villanueva V. Spanish consensus on the management of concomitant antiseizure medications when using cenobamate in adults with drug-resistant focal seizures. Epilepsia Open 2024. [PMID: 38573131 DOI: 10.1002/epi4.12936] [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: 01/22/2024] [Revised: 03/08/2024] [Accepted: 03/24/2024] [Indexed: 04/05/2024] Open
Abstract
OBJECTIVE Cenobamate is an antiseizure medication (ASM) associated with high rates of seizure freedom and acceptable tolerability in patients with focal seizures. To achieve the optimal cenobamate dose for maximal potential effectiveness while avoiding or minimizing drug-related adverse events (AEs), the administration of cenobamate with other ASMs must be managed through concomitant ASM load reduction. A panel of Spanish epilepsy experts aimed to provide a Spanish consensus on how to adjust the dose of concomitant ASMs in patients with drug-resistant epilepsy (DRE) in order to improve the effectiveness and tolerability of adjunctive cenobamate. METHODS A three-stage modified Delphi consensus process was undertaken, including six Spanish epileptologists with extensive experience using cenobamate. Based on current literature and their own expert opinion, the expert panel reached a consensus on when and how to adjust the dosage of concomitant ASMs during cenobamate titration. RESULTS The expert panel agreed that tailored titration and close follow-up are required to achieve the best efficacy and tolerability when initiating cenobamate in patients receiving concomitant ASMs. When concomitant clobazam, phenytoin, phenobarbital, and sodium channel blockers are taken at high dosages, or when the patient is receiving two or more sodium channel blockers, dosages should be proactively lowered during the cenobamate titration period. Other concomitant ASMs should be reduced only if the patient reports a moderate/severe AE at any stage of the titration period. SIGNIFICANCE Cenobamate is an effective ASM with a dose-dependent effect. To maximize effectiveness while maintaining the best tolerability profile, co-medication management is needed. The recommendations included herein provide practical guidance for proactive and reactive management of co-medication in cenobamate-treated patients with DRE and a high drug load. PLAIN LANGUAGE SUMMARY Patients with epilepsy may continue to have seizures even after treatment with several different antiseizure medications (ASMs). Cenobamate is an ASM that can reduce seizures in these patients. In this study, six Spanish experts in epilepsy discussed the best way to use cenobamate in drug-resistant epilepsy. They provide practical guidance on when and how the dose of other ASMs might be adjusted to reduce side effects and optimize the use of cenobamate.
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Affiliation(s)
- Mar Carreño
- Hospital Clinic Barcelona, Epilepsy Unit, Barcelona, Spain
| | - Antonio Gil-Nagel
- Department of Neurology, Epilepsy Program, Ruber International Hospital, Madrid, Spain
| | - José M Serratosa
- Department of Neurology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Manuel Toledo
- Vall d'Hebron University Hospital, Epilepsy Unit, Barcelona, Spain
| | | | - Vicente Villanueva
- La Fe University and Polytechnic Hospital, Refractory Epilepsy Unit, Valencia, Spain
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Matricardi S, Scorrano G, Prezioso G, Burchiani B, Di Cara G, Striano P, Chiarelli F, Verrotti A. The latest advances in the pharmacological management of focal epilepsies in children: a narrative review. Expert Rev Neurother 2024; 24:371-381. [PMID: 38433525 DOI: 10.1080/14737175.2024.2326606] [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: 01/22/2024] [Accepted: 02/29/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Focal epilepsy constitutes the most common epilepsy in children, and medical treatment represents the first-line therapy in this condition. The main goal of medical treatment for children and adolescents with epilepsy is the achievement of seizure freedom or, in drug-resistant epilepsies, a significant seizure reduction, both minimizing antiseizure medications (ASM)-related adverse events, thus improving the patient's quality of life. However, up to 20-40% of pediatric epilepsies are refractory to drug treatments. New ASMs came to light in the pediatric landscape, improving the drug profile compared to that of the preexisting ones. Clinicians should consider several factors during the drug choice process, including patient and medication-specific characteristics. AREAS COVERED This narrative review aims to summarize the latest evidence on the effectiveness and tolerability of the newest ASMs administered as monotherapy or adjunctive therapy in pediatric epilepsies with focal onset seizures, providing a practical appraisal based on the existing evidence. EXPERT OPINION The latest ASMs have the potential to be effective in the pharmacological management of focal onset seizures in children, and treatment choice should consider several drug- and epilepsy-related factors. Future treatments should be increasingly personalized and targeted on patient-specific pathways. Future research should focus on discovering new chemical compounds and repurposing medications used for other indications.
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Affiliation(s)
- Sara Matricardi
- Department of Paediatrics, University of Chieti, Chieti, Italy
| | | | | | | | - Giuseppe Di Cara
- Department of Paediatrics, University of Perugia, Perugia, Italy
| | - Pasquale Striano
- Paediatric Neurology and Muscular Disease Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | | | - Alberto Verrotti
- Department of Paediatrics, University of Perugia, Perugia, Italy
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Ferrari L, Rosenfeld WE, Kamin M. A global update on cenobamate based on real-world experience in over 100 000 patients. Epilepsia 2024; 65:1149-1150. [PMID: 38446133 DOI: 10.1111/epi.17935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 02/16/2024] [Indexed: 03/07/2024]
Affiliation(s)
| | - William E Rosenfeld
- Comprehensive Epilepsy Care Center for Children and Adults, St. Louis, MO, USA
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O'Dwyer R, Stern S, Wade CT, Guggilam A, Rosenfeld WE. Safety and Efficacy of Cenobamate for the Treatment of Focal Seizures in Older Patients: Post Hoc Analysis of a Phase III, Multicenter, Open-Label Study. Drugs Aging 2024; 41:251-260. [PMID: 38446341 PMCID: PMC10925560 DOI: 10.1007/s40266-024-01102-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Cenobamate is an antiseizure medication (ASM) approved in the US and Europe for the treatment of uncontrolled focal seizures. OBJECTIVE This post hoc analysis of a phase III, open-label safety study assessed the safety and efficacy of adjunctive cenobamate in older adults versus the overall study population. METHODS Adults aged 18-70 years with uncontrolled focal seizures taking stable doses of one to three ASMs were enrolled in the phase III, open-label safety study; adults aged 65-70 years from that study were included in our safety analysis. Discontinuations due to adverse events and treatment-emergent adverse events (TEAEs) were assessed throughout the study in all patients who received one or more doses of cenobamate (safety study population). Efficacy was assessed post hoc in patients who had adequate seizure data available (post hoc efficacy population); we assessed patients aged 65-70 years from that population. Overall, 100% responder rates were assessed in the post hoc efficacy maintenance-phase population in 3-month intervals. Concomitant ASM drug load changes were also measured. For each ASM, drug load was defined as the ratio of actual drug dose/day to the World Health Organization defined daily dose (DDD). RESULTS Of 1340 patients (mean age 39.7 years) in the safety study population, 42 were ≥ 65 years of age (mean age 67.0 years, 52.4% female). Median duration of exposure was 36.1 and 36.9 months for overall patients and older patients, respectively, and mean epilepsy duration was 22.9 and 38.5 years, respectively. At 1, 2, and 3 years, 80%, 72%, and 68% of patients overall, and 76%, 71%, and 69% of older patients, respectively, remained on cenobamate. Common TEAEs (≥ 20%) were somnolence and dizziness in overall patients, and somnolence, dizziness, fall, fatigue, balance disorder, and upper respiratory tract infection in older patients. Falls in older patients occurred after a mean 452.1 days of adjunctive cenobamate treatment (mean dose 262.5 mg/day; mean concomitant ASM drug load 2.46). Of 240 patients in the post hoc efficacy population, 18 were ≥ 65 years of age. Mean seizure frequency at baseline was 18.1 seizures/28 days for the efficacy population and 3.1 seizures/28 days for older patients. Rates of 100% seizure reduction within 3-month intervals during the maintenance phase increased over time for the overall population (n = 214) and older adults (n = 15), reaching 51.9% and 78.6%, respectively, by 24 months. Mean percentage change in concomitant ASM drug load, not including cenobamate, was reduced in the overall efficacy population (31.8%) and older patients (36.3%) after 24 months of treatment. CONCLUSIONS Results from this post hoc analysis showed notable rates of efficacy in older patients taking adjunctive cenobamate. Rates of several individual TEAEs occurred more frequently in older patients. Further reductions in concomitant ASMs may be needed in older patients when starting cenobamate to avoid adverse effects such as somnolence, dizziness, and falls. CLINICAL TRIALS REGISTRATION ClinicalTrials.gov NCT02535091.
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Affiliation(s)
- Rebecca O'Dwyer
- Epilepsy Section, Department of Neurological Sciences, Comprehensive Epilepsy Clinic for Elderly, Rush University Medical Center, 1725 W. Harrison Street, Suite 885, Chicago, IL, 60612, USA.
| | | | | | | | - William E Rosenfeld
- Comprehensive Epilepsy Care Center for Children and Adults, St. Louis, MO, USA
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Novitskaya Y, Schütz E, Metternich B, Schulze-Bonhage A, Hirsch M. Add-on treatment with cenobamate is already effective at low doses in refractory focal epilepsy: A prospective observational study. Epilepsia 2024; 65:630-640. [PMID: 38135903 DOI: 10.1111/epi.17874] [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: 08/18/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 12/24/2023]
Abstract
OBJECTIVE Cenobamate, a novel antiseizure medication with a dual mechanism of action, has been shown in pivotal trials to significantly improve seizure control in treatment-resistant focal epilepsy. We aimed to evaluate whether these promising results could be confirmed in a real-world setting with a follow-up period of up to 12 months. METHODS Patients from a tertiary epilepsy center who received cenobamate add-on between June 2021 and October 2023 were followed up prospectively at 3, 6, and 12 months after treatment initiation for assessment of seizure outcomes and treatment-related adverse events. RESULTS The clinical cohort included 112 adult patients with 30% nonlesional cases and a wide spectrum of epileptogenic lesions underlying refractory focal epilepsy. We observed a significant reduction in monthly seizure frequency of all seizure types already after 3 months of treatment at a median cenobamate dose of 100 mg/day. Forty-six percent of patients were responders with a ≥50% seizure reduction, 26% had a ≥75% seizure reduction, and 9% became seizure-free. Among the 74 patients with available follow-up of 12 months, the responder rates reached 55%, 35%, and 19% for ≥50%, ≥75%, and 100% seizure reduction, respectively. After 3 months of treatment, 38% of patients reported adverse effects, mainly (84%) mild to moderate in intensity. Adjustment of comedication allowed successful management of adverse effects in 32% of patients. At a group level, there was no correlation between the cenobamate daily dose and the incidence of adverse events. SIGNIFICANCE We found a clinically relevant response to cenobamate already at a low daily dose of 100 mg also in a patient cohort with a higher degree of drug resistance than in pivotal trials. Our prospectively collected data provide real-world evidence for high efficacy and good tolerability of the drug, although no standardized treatment protocol or comparison with a control group was applied.
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Affiliation(s)
- Yulia Novitskaya
- Department of Neurosurgery, Freiburg Epilepsy Center, Medical Center, University of Freiburg, Freiburg, Germany
| | - Elisa Schütz
- Department of Neurosurgery, Freiburg Epilepsy Center, Medical Center, University of Freiburg, Freiburg, Germany
| | - Birgitta Metternich
- Department of Neurosurgery, Freiburg Epilepsy Center, Medical Center, University of Freiburg, Freiburg, Germany
| | - Andreas Schulze-Bonhage
- Department of Neurosurgery, Freiburg Epilepsy Center, Medical Center, University of Freiburg, Freiburg, Germany
| | - Martin Hirsch
- Department of Neurosurgery, Freiburg Epilepsy Center, Medical Center, University of Freiburg, Freiburg, Germany
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Molteni L, Charlier B, Coglianese A, Izzo V, Assenza G, Menna P, de Grazia U, D’Urso A. Quantitative Analysis of Cenobamate and Concomitant Anti-Seizure Medications in Human Plasma via Ultra-High Performance Liquid Chromatography-Tandem Mass Spectrometry. Molecules 2024; 29:884. [PMID: 38398636 PMCID: PMC10892084 DOI: 10.3390/molecules29040884] [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: 12/12/2023] [Revised: 01/26/2024] [Accepted: 02/13/2024] [Indexed: 02/25/2024] Open
Abstract
Cenobamate (CNB) is a new anti-seizure medication (ASM) recently introduced in clinical practice after approval by the FDA and EMA for the add-on treatment of focal onset seizures in adult patients. Although its mechanism of action has not been fully understood, CNB showed promising clinical efficacy in patients treated with concomitant ASMs. The accessibility of CNB could pave a way for the treatment of refractory or drug-resistant epilepsies, which still affect at least one-third of the patients under pharmacological treatment. In this context, therapeutic drug monitoring (TDM) offers a massive opportunity for better management of epileptic patients, especially those undergoing combined therapy. Here, we describe the first fully validated ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) method for the quantification of CNB and concomitant ASMs in human plasma, with samples extracted either manually or by means of a liquid handler. Our method was validated according to the most recent ICH International Guideline M10 for Bioanalytical Method Validation and Study Sample Analysis. The method proved to be selective for CNB and displayed a linear range from 0.8 to 80 mg/L; no matrix effect was found (98.2 ± 4.1%), while intra-day and inter-day accuracy and precision were within the acceptance range. Also, CNB short- and long-term stability in plasma under different conditions was assessed. Leftover human plasma samples were employed as study samples for method validation. Our method proved to be highly sensitive and selective to quantify CNB and concomitant ASMs in human plasma; therefore, this method can be employed for a routinely TDM-based approach to support physicians in the management of an epileptic patient.
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Affiliation(s)
- Linda Molteni
- SSD Laboratory Medicine, Fondazione IRCCS “Istituto Neurologico Carlo Besta”, 20133 Milan, Italy;
| | - Bruno Charlier
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Baronissi, 84081 Salerno, Italy; (B.C.); (A.C.); (V.I.)
- University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy
| | - Albino Coglianese
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Baronissi, 84081 Salerno, Italy; (B.C.); (A.C.); (V.I.)
- Graduate School in Clinical Pathology and Clinical Biochemistry, University of Salerno, Baronissi, 84081 Salerno, Italy
| | - Viviana Izzo
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Baronissi, 84081 Salerno, Italy; (B.C.); (A.C.); (V.I.)
- University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy
| | - Giovanni Assenza
- Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy; (G.A.); (P.M.)
| | - Pierantonio Menna
- Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy; (G.A.); (P.M.)
- Department of Science and Technology for Sustainable Development and One Health, University Campus Biomedico di Roma, 00128 Rome, Italy
| | - Ugo de Grazia
- SSD Laboratory Medicine, Fondazione IRCCS “Istituto Neurologico Carlo Besta”, 20133 Milan, Italy;
| | - Annachiara D’Urso
- SSD Laboratory Medicine, Fondazione IRCCS “Istituto Neurologico Carlo Besta”, 20133 Milan, Italy;
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Aboumatar S, Ferrari L, Stern S, Wade CT, Weingarten M, Connor GS, Rosenfeld WE. Reductions in concomitant antiseizure medication drug load during adjunctive cenobamate therapy: Post-hoc analysis of a subset of patients from a phase 3, multicenter, open-label study. Epilepsy Res 2024; 200:107306. [PMID: 38340681 DOI: 10.1016/j.eplepsyres.2024.107306] [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: 08/17/2023] [Revised: 01/05/2024] [Accepted: 01/15/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVE Many patients with epilepsy require polytherapy, which increases their antiseizure medication (ASM) drug load, a measure that considers the doses of all ASMs a patient is taking. Changes in concomitant ASM drug load after adding cenobamate were evaluated post-hoc in a subset of the open-label, phase 3 study. METHODS Patients 18-70 years old with uncontrolled focal seizures taking 1-3 ASMs were enrolled. Total concomitant ASM drug load (not including cenobamate) was calculated by dividing the patient's prescribed dose for each ASM by its defined daily dose, per the World Health Organization, then summing the ratios. Changes in concomitant ASM drug load were measured from baseline in 3-month intervals up to 24 months by both total and class-specific ASM drug load. Subgroups of interest included: older adults (65-70 years), prior epilepsy-related surgery vs none, and baseline seizure frequency < 3 vs ≥ 3 seizures/28 days. RESULTS Data from 240 patients were available (mean age 41.8 years, mean baseline drug load 3.57). Following cenobamate initiation, the mean concomitant ASM drug load was reduced by 29.4 % at Month 12 % and 31.8 % at Month 24. Reductions occurred in all assessed ASM drug classes, with the largest reduction in benzodiazepines (55.2 % at Month 24). Each assessed subgroup exceeded a 30 % reduction in concomitant ASM drug load at Month 24. Over 24 months, maintenance of ≥ 50 % response occurred in 89.3 %, 86.4 %, and 90.6 % of patients with low (-0.25 to <0), moderate (-0.59 to -0.25), or high (-3.3 to -0.59) numerical reductions in concomitant ASM drug load from baseline, respectively, compared with 86.0 % in patients with no change in drug load; maintenance of 100 % response occurred in 80.7 %, 84.3 %, and 70.0 % of patients with low, moderate, or high numerical reductions in concomitant ASM drug load, compared with 82.0 % in patients with no change. CONCLUSIONS Adding cenobamate led to reduced mean concomitant ASM drug loads during 1 and 2 years of treatment. Reductions occurred regardless of ASM drug class, patient age, or epilepsy disease characteristics and did not impact maintenance of response rates.
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Affiliation(s)
- Sami Aboumatar
- Austin Epilepsy Care Center, 2200 Park Bend Drive, Building 2, Suite 203, Austin, TX 78758, USA.
| | - Louis Ferrari
- SK Life Science, Inc., 461 From Road, Fifth Floor, Paramus, NJ 07652, USA
| | - Sean Stern
- SK Life Science, Inc., 461 From Road, Fifth Floor, Paramus, NJ 07652, USA
| | - Clarence T Wade
- SK Life Science, Inc., 461 From Road, Fifth Floor, Paramus, NJ 07652, USA
| | - Mindl Weingarten
- SK Life Science, Inc., 461 From Road, Fifth Floor, Paramus, NJ 07652, USA
| | - Gregory S Connor
- Neurological Center of Oklahoma, 6585 South Yale Avenue, Suite 620, Tulsa, OK 74136, USA
| | - William E Rosenfeld
- Comprehensive Epilepsy Care Center for Children and Adults, 11134 Conway Road, St. Louis, MO 63131, USA
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12
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Krauss GL, Chung SS, Ferrari L, Stern S, Rosenfeld WE. Cognitive and psychiatric adverse events during adjunctive cenobamate treatment in phase 2 and phase 3 clinical studies. Epilepsy Behav 2024; 151:109605. [PMID: 38184949 DOI: 10.1016/j.yebeh.2023.109605] [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: 09/29/2023] [Revised: 12/15/2023] [Accepted: 12/21/2023] [Indexed: 01/09/2024]
Abstract
OBJECTIVE Cognitive and psychiatric adverse events in patients with epilepsy are important determinants of therapeutic outcomes and patient quality of life. We assessed the relationship between adjunctive cenobamate treatment and selected cognitive and psychiatric treatment-emergent adverse events (TEAEs) in adults with uncontrolled focal epilepsy. METHODS This was a retrospective analysis of pooled populations of patients with focal epilepsy from two phase 2, randomized, double-blind clinical trials; two open-label extensions (OLEs) of those trials; and a long-term, open-label, phase 3 safety study. Occurrence of cognitive and psychiatric TEAEs in patients treated with adjunctive cenobamate or placebo during double-blind treatment were evaluated. Exposure-adjusted incidence rates of the cognitive and psychiatric TEAEs, defined as the number of TEAEs per patient-year of treatment, during up to 7 years of long-term adjunctive cenobamate treatment, were determined in the pooled OLE and phase 3 patient populations. RESULTS The pooled randomized trials resulted in a population of 442 patients treated with cenobamate (100 mg/day: n = 108; 200 mg/day: n = 223; 400 mg/day: n = 111) and 216 placebo-treated patients. The combined open-label studies resulted in pooled populations of cenobamate-treated patients ranging from n = 1690 during Year 1 to n = 103 during Year 7. Among cenobamate-treated (all doses) and placebo-treated patients during double-blind treatment, cognitive TEAEs were reported by ≤ 1.9 % (range, 0 %-1.9 %) and ≤ 0.5 % (range, 0 %-0.5 %), respectively, and psychiatric TEAEs by ≤ 3.6 % (range, 0 %-3.6 %) and ≤ 3.2 % (range, 0 %-3.2 %), respectively. During up to 7 years of open-label adjunctive cenobamate treatment, exposure-adjusted incidence rates of cognitive and psychiatric TEAEs were < 0.018 and < 0.038 events per patient-year, respectively. Discontinuation of adjunctive cenobamate due to cognitive or psychiatric TEAEs assessed in this study during double-blind or open-label treatment occurred in ≤ 0.3 % and ≤ 1.7 % of patients, respectively. CONCLUSIONS Cognitive and psychiatric TEAEs were reported by similar numbers of cenobamate- and placebo-treated patients during double-blind adjunctive cenobamate treatment (< 4 % of patients), and exposure-adjusted incidence rates of these TEAEs remained low during open-label cenobamate treatment for up to 7 years. Treatment discontinuations due to these TEAEs were rare. The results of this post-hoc analysis indicate that adjunctive cenobamate treatment exhibits a low incidence of cognitive or psychiatric TEAEs in patients with uncontrolled focal seizures.
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Affiliation(s)
- Gregory L Krauss
- Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21287, USA.
| | - Steve S Chung
- Neuroscience Institute, Banner-University Medical Center, 755 East McDowell Road, Phoenix, AZ 85006.
| | - Louis Ferrari
- SK Life Science, Inc., 461 From Road, Fifth Floor, Paramus, NJ 07652, USA.
| | - Sean Stern
- SK Life Science, Inc., 461 From Road, Fifth Floor, Paramus, NJ 07652, USA.
| | - William E Rosenfeld
- Comprehensive Epilepsy Care Center for Children and Adults, 11134 Conway Road, St. Louis, MO 63131, USA.
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13
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Catalán‐Aguilar J, Hampel KG, Cano‐López I, Garcés M, Lozano‐García A, Tormos‐Pons P, González‐Bono E, Villanueva V. Prospective study of cenobamate on cognition, affectivity, and quality of life in focal epilepsy. Epilepsia Open 2024; 9:223-235. [PMID: 37920923 PMCID: PMC10839366 DOI: 10.1002/epi4.12857] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/27/2023] [Indexed: 11/04/2023] Open
Abstract
OBJECTIVE Cenobamate is a recently approved antiseizure medication that proved to be safe and effective in randomized controlled trials. However, little is known about its impact on some areas frequently affected by epilepsy. For this reason, we explored the effects of cenobamate on cognitive performance, as well as on negative affectivity and quality of life in a sample of patients with drug-resistant epilepsy. METHODS Two prospective cohort studies were carried out. In Study 1, 32 patients (22 men and 10 women) underwent a baseline (T0) and a short-term (T1) neuropsychological assessment after 3 months of cenobamate administration. In Study 2, 22 patients (16 men and 6 women) from the T1 sample also underwent a baseline and a follow-up evaluation (T2) 6 months after T0. RESULTS No significant differences were found in cognitive variables, negative affectivity, and quality of life either in Study 1 or Study 2. Similarly, based on the reliable change index, it was found that most patients showed no changes in these variables. SIGNIFICANCE These results suggest that cenobamate is a safe antiseizure medication in terms of cognition, negative affectivity, or quality of life since no adverse events have been found after 3 and 6 months of treatment. PLAIN LANGUAGE SUMMARY Cenobamate is a new antiseizure medication. In patients with epilepsy, cenobamate seems to not affect cognition, anxiety, depression, or quality of life.
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Affiliation(s)
- Judit Catalán‐Aguilar
- Institut d'Investigació en Psicologia dels Recursos Humans, del Desenvolupament Organitzacional i de la Qualitat de Vida Laboral (Idocal)/Department of Psychobiology, Psychology CenterUniversitat de València. Av. Blasco IbáñezValenciaSpain
| | - Kevin G. Hampel
- Refractory Epilepsy Unit, Neurology Service, Member of ERN EPICAREHospital Universitario y Politécnico La Fe. Av. Fernando Abril MartorellValenciaSpain
| | - Irene Cano‐López
- Institut d'Investigació en Psicologia dels Recursos Humans, del Desenvolupament Organitzacional i de la Qualitat de Vida Laboral (Idocal)/Department of Psychobiology, Psychology CenterUniversitat de València. Av. Blasco IbáñezValenciaSpain
| | - Mercedes Garcés
- Refractory Epilepsy Unit, Neurology Service, Member of ERN EPICAREHospital Universitario y Politécnico La Fe. Av. Fernando Abril MartorellValenciaSpain
| | - Alejandro Lozano‐García
- Faculty of Health SciencesValencian International UniversityValenciaSpain
- Department of PsychologyUniversidad Europea de ValenciaValenciaSpain
- Faculty of Health SciencesUniversidad Isabel IBurgosSpain
| | - Paula Tormos‐Pons
- Institut d'Investigació en Psicologia dels Recursos Humans, del Desenvolupament Organitzacional i de la Qualitat de Vida Laboral (Idocal)/Department of Psychobiology, Psychology CenterUniversitat de València. Av. Blasco IbáñezValenciaSpain
| | - Esperanza González‐Bono
- Institut d'Investigació en Psicologia dels Recursos Humans, del Desenvolupament Organitzacional i de la Qualitat de Vida Laboral (Idocal)/Department of Psychobiology, Psychology CenterUniversitat de València. Av. Blasco IbáñezValenciaSpain
| | - Vicente Villanueva
- Refractory Epilepsy Unit, Neurology Service, Member of ERN EPICAREHospital Universitario y Politécnico La Fe. Av. Fernando Abril MartorellValenciaSpain
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Hullett PW, Lowenstein DH. Major advances in epilepsy research in 2023. Lancet Neurol 2024; 23:19-20. [PMID: 38101887 DOI: 10.1016/s1474-4422(23)00457-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 11/20/2023] [Indexed: 12/17/2023]
Affiliation(s)
- Patrick W Hullett
- Department of Neurology, University of California, San Francisco, CA 94143, USA.
| | - Daniel H Lowenstein
- Department of Neurology, University of California, San Francisco, CA 94143, USA
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15
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Schmitz B, Lattanzi S, Vonck K, Kälviäinen R, Nashef L, Ben‐Menachem E. Cenobamate in refractory epilepsy: Overview of treatment options and practical considerations. Epilepsia Open 2023; 8:1241-1255. [PMID: 37743544 PMCID: PMC10690671 DOI: 10.1002/epi4.12830] [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: 05/24/2023] [Accepted: 09/18/2023] [Indexed: 09/26/2023] Open
Abstract
Management of drug resistant epilepsy (DRE) represents a challenge to the treating clinician. This manuscript addresses DRE and provides an overview of treatment options, medical, surgical, and dietary. It addresses treatment strategies in polytherapy, then focuses on the role cenobamate (CNB) may play in reducing the burden of DRE while providing practical advice for its introduction. CNB is a recently approved, third generation, anti-seizure medication (ASM), a tetrazole-derived carbamate, thought to have a dual mechanism of action, through its effect on sodium channels as well as on GABAA receptors at a non-benzodiazepine site. CNB, having a long half-life, is an effective add-on ASM in refractory focal epilepsy with a higher response rate and a higher seizure-freedom rate than is usually seen in regulatory clinical trials. Experience post-licensing, though still limited, supports the findings of clinical trials and is encouraging. Its spectrum of action in relation to generalized epilepsies and seizures remains to be established, and there are no data on its efficacy in monotherapy. At the time of writing, CNB has been prescribed for some 50 000 individuals with DRE and focal epilepsy. A larger number is needed to fully establish its safety profile. It should at all times be introduced slowly to minimize the risk of serious allergic drug reactions. It has clinically meaningful interactions which must be anticipated and managed to maximize tolerability and likelihood of successful treatment. Despite the above, it may well prove to be of major benefit in the treatment of many patients with drug resistant epilepsy.
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Affiliation(s)
- Bettina Schmitz
- Center for Epilepsy, Department for NeurologyVivantes Humboldt‐KlinikumBerlinGermany
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical MedicineMarche Polytechnic UniversityAnconaItaly
| | - Kristl Vonck
- Department of Neurology, 4BrainGhent University HospitalGentBelgium
| | - Reetta Kälviäinen
- Kuopio Epilepsy Center, Kuopio University Hospital, Member of ERN EpiCARE, and Institute of Clinical MedicineUniversity of Eastern FinlandKuopioFinland
| | - Lina Nashef
- Neurology DepartmentKing's College HospitalLondonUK
| | - Elinor Ben‐Menachem
- Institution for Clinical Neuroscience, Sahlgrenska AcademyUniversity of GoteborgGoteborgSweden
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16
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Stern S, Weingarten M, Mandapati S, Ferrari L, Wade CT. Real-world analysis of retention on cenobamate in patients with epilepsy in the United States. Epilepsy Res 2023; 197:107207. [PMID: 37741165 DOI: 10.1016/j.eplepsyres.2023.107207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 08/10/2023] [Accepted: 08/14/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND This retrospective, observational study used US claims data to assess retention rates on cenobamate compared with four branded antiseizure medications (ASMs) in patients with epilepsy. METHODS Adults (≥18 years) with prevalent epilepsy (ICD-10 code G40.xx) and ≥ 1 prescription for cenobamate or any of the newer branded ASMs (brivaracetam, eslicarbazepine, lacosamide, or perampanel) between May 1, 2020 and December 31, 2021 were identified from the HealthVerity Marketplace database. At least 360 days of continuous enrollment was required before and after the index date (Day 1 of initiating cenobamate or branded ASM). Patients were followed until cessation of cenobamate or branded ASM or the end of data collection using Kaplan-Meier methods. Retention was compared between cenobamate and the branded ASMs (both as a group and individually) using Chi-square tests. RESULTS In total, 4109 patients were included (195 cenobamate; 3914 branded ASMs). A higher proportion of patients in the cenobamate group compared with the branded ASMs group had concurrent focal and generalized epilepsy (65.6% vs 40.0%) and were on ≥ 3 concomitant ASMs (48.2% vs 12.8%) at the index date. Median time to discontinuation (i.e., the time that half the patients discontinued) was not quite reached after 12 months in the cenobamate group (50.3% of patients remained on cenobamate) and was 7.7 months in the branded ASMs group. Retention was significantly higher with cenobamate vs the branded ASMs group (p = 0.04545) and vs the individual ASMs lacosamide (p = 0.03044) and perampanel (p = 0.01558). Twelve-month retention rates (95% confidence intervals) were 50.3% (43.1%-57.0%) for cenobamate, 40.5% (38.9%-42.0%) for branded ASMs overall, 42.3% (38.6%-46.0%) for brivaracetam, 44.1% (39.2%-49.0%) for eslicarbazepine, 39.9% (38.0%-41.8%) for lacosamide, and 36.8% (31.9%-41.8%) for perampanel. CONCLUSIONS In this real-world analysis, retention was significantly higher with cenobamate vs a pooled group of four branded ASMs despite a greater frequency of patients in the cenobamate group having characteristics of more difficult-to-treat epilepsy.
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Affiliation(s)
- Sean Stern
- SK Life Science, Inc., Paramus, NJ, USA.
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17
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Becker DA, Demko SA. Dose reduction and discontinuation of concomitant antiseizure medications after initiating cenobamate: A retrospective review. Epilepsy Res 2023; 197:107242. [PMID: 37871541 DOI: 10.1016/j.eplepsyres.2023.107242] [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: 02/13/2023] [Revised: 09/07/2023] [Accepted: 10/08/2023] [Indexed: 10/25/2023]
Abstract
This retrospective chart review examined dose reductions and discontinuations of concomitant antiseizure medications (ASMs) following cenobamate initiation and maintenance in patients with epilepsy treated at MetroHealth (Cleveland, OH) between 9/1/2020-9/26/2022. Concomitant ASM dose adjustments and treatment-emergent adverse events (TEAEs) were assessed. Efficacy (100 % seizure reduction) was examined among patients who received cenobamate for ≥ 3 months at data cutoff (including titration). As of 9/26/2022, 95 patients received cenobamate (mean age, 45.9 years; 48.4 % female, median exposure 7.5 months). Five patients (5.3 %) discontinued (n = 1 withdrawal by patient; n = 1 noncompliance; n = 3 adverse event). Among the 90 patients taking cenobamate at data cutoff, 50 % (45/90) discontinued ≥ 1 concomitant ASM, most commonly clobazam (n = 18), levetiracetam (n = 10), and phenytoin (n = 7); 21 patients (23.3 %) had additional concomitant ASM dose reductions, most commonly phenytoin (n = 6) and clobazam (n = 4). Sixteen patients received cenobamate monotherapy. Among 79 patients who received cenobamate for ≥ 3 months at data cutoff, 51.9 % (41/79) were seizure-free for ≥ 3 months. Of the 41 seizure-free patients, 58.5 % (24/41) were taking 100 mg/day of cenobamate. Sixteen of the 95 cenobamate-treated patients (16.8 %) reported 22 TEAEs. The most common TEAE was fatigue (n = 7). These data suggest that cenobamate therapy may allow reduction or elimination of polytherapy in some patients.
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Affiliation(s)
- Danielle A Becker
- MetroHealth, 2500 MetroHealth Drive, Cleveland, OH 44109, USA; Department of Neurology, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA.
| | - Sarah A Demko
- MetroHealth, 2500 MetroHealth Drive, Cleveland, OH 44109, USA
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18
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Vossler DG, Rosenfeld WE, Stern S, Wade CT, Ferrari L, Kerr WT, Wechsler R. Sustainability of seizure reduction and seizure control with adjunctive cenobamate: Post hoc analysis of a phase 3, open-label study. Epilepsia 2023; 64:2644-2652. [PMID: 37497579 DOI: 10.1111/epi.17724] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 07/20/2023] [Accepted: 07/24/2023] [Indexed: 07/28/2023]
Abstract
OBJECTIVE In this post hoc analysis of a subset of patients from a long-term, open-label phase 3 study, we assessed ≥50%, ≥75%, ≥90%, and 100% seizure reduction and sustainability of these responses with cenobamate using a time-to-event analytical approach. METHODS Of 240 patients with uncontrolled focal seizures who had adequate seizure data available, 214 completed the 12-week titration phase and received ≥1 dose of cenobamate in the maintenance phase (max dose 400 mg/day) and were included in this post hoc analysis. Among patients who met an initial given seizure-reduction level (≥50%, ≥75%, ≥90%, or 100%), sustainability of that response was measured using a time-to-event methodology. An event was defined as the occurrence of a study visit at which the seizure frequency during the interval since the prior study visit exceeded the initially attained reduction level. Study visits during the maintenance phase occurred at 3-month intervals. RESULTS Of the 214 patients analyzed, 188 (88%), 177 (83%), 160 (75%), and 145 (68%) met ≥50%, ≥75%, ≥90%, and 100% seizure-reduction responses, respectively, for at least one study visit interval during the maintenance phase. The median (95% confidence interval [CI]) time to first visit without a ≥50% seizure reduction was not reached by 30 months of follow-up (53% of patients maintained their initial ≥50% seizure reduction). Median (95% CI) time to first visit without sustaining the initial ≥75%, ≥90%, or 100% seizure reduction was 13.0 (7.5-21.9) months, 7.5 (5.4-11.6) months, and 7.0 (5.3-10.4) months, respectively. Among the 145 patients who had 100% seizure reduction during at least one study visit, 22% remained seizure-free for at least 30 months and 63% had ≤3 study visits with seizures. SIGNIFICANCE Adjunctive treatment with cenobamate led to sustained seizure reductions during the maintenance phase of the phase 3 safety study.
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Affiliation(s)
- David G Vossler
- University of Washington School of Medicine, Seattle, Washington, USA
| | - William E Rosenfeld
- Comprehensive Epilepsy Care Center for Children and Adults, St. Louis, Missouri, USA
| | - Sean Stern
- SK Life Science Inc., Paramus, New Jersey, USA
| | | | | | - Wesley T Kerr
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Robert Wechsler
- Consultants in Epilepsy & Neurology and Idaho Comprehensive Epilepsy Center, Boise, Idaho, USA
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Villanueva V, Santos‐Carrasco D, Cabezudo‐García P, Gómez‐Ibáñez A, Garcés M, Serrano‐Castro P, Castro‐Vilanova MD, Sayas D, Lopez‐Gonzalez FJ, Rodríguez‐Osorio X, Torres‐Gaona G, Saiz‐Diaz RA, Hampel KG, Martinez‐Ferri M, Aguilar‐Amat MJ, Mercedes‐Alvarez B, García‐Morales V, del Villar‐Igea A, Massot‐Tarrús A, Rodríguez‐Uranga JJ. Real-world safety and effectiveness of cenobamate in patients with focal onset seizures: Outcomes from an Expanded Access Program. Epilepsia Open 2023; 8:918-929. [PMID: 37149853 PMCID: PMC10472366 DOI: 10.1002/epi4.12757] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/03/2023] [Indexed: 05/09/2023] Open
Abstract
OBJECTIVE This study investigated early, real-world outcomes with cenobamate (CNB) in a large series of patients with highly drug-resistant epilepsy within a Spanish Expanded Access Program (EAP). METHOD This was a multicenter, retrospective, observational study in 14 hospitals. Inclusion criteria were age ≥18 years, focal seizures, and EAP authorization. Data were sourced from patient clinical records. Primary effectiveness endpoints included reductions (100%, ≥90%, ≥75%, and ≥50%) or worsening in seizure frequency at 3-, 6-, and 12-month visits and at the last visit. Safety endpoints included rates of adverse events (AEs) and AEs leading to discontinuation. RESULTS The study included 170 patients. At baseline, median epilepsy duration was 26 years and median number of seizures/month was 11.3. The median number of prior antiseizure medications (ASMs) and concomitant ASMs were 12 and 3, respectively. Mean CNB dosages/day were 176 mg, 200 mg, and 250 mg at 3, 6, and 12 months. Retention rates were 98.2%, 94.5%, and 87% at 3, 6, and 12 months. At last available visit, the rate of seizure freedom was 13.3%; ≥90%, ≥75%, and ≥50% responder rates were 27.9%, 45.5%, and 63%, respectively. There was a significant reduction in the number of seizures per month (mean: 44.6%; median: 66.7%) between baseline and the last visit (P < 0.001). Responses were maintained regardless of the number of prior or concomitant ASMs. The number of concomitant ASMs was reduced in 44.7% of patients. The cumulative percentage of patients with AEs and AEs leading to discontinuation were 68.2% and 3.5% at 3 months, 74.1% and 4.1% at 6 months, and 74.1% and 4.1% at 12 months. The most frequent AEs were somnolence and dizziness. SIGNIFICANCE In this highly refractory population, CNB showed a high response regardless of prior and concomitant ASMs. AEs were frequent but mostly mild-to-moderate, and few led to discontinuation.
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Affiliation(s)
- Vicente Villanueva
- Hospital Universitario y Politécnico La Fe, Member of EPICAREValenciaSpain
| | - Daniel Santos‐Carrasco
- Centro Neurología AvanzadaSevillaSpain
- Departamento de Psicología ExperimentalUniversidad de SevillaSevillaSpain
| | | | | | - Mercedes Garcés
- Hospital Universitario y Politécnico La Fe, Member of EPICAREValenciaSpain
| | | | | | - Débora Sayas
- Hospital Universitario y Politécnico La Fe, Member of EPICAREValenciaSpain
| | | | | | | | | | - Kevin G. Hampel
- Hospital Universitario y Politécnico La Fe, Member of EPICAREValenciaSpain
| | | | - Maria J. Aguilar‐Amat
- Instituto de Investigación Sanitaria del Hospital Universitario La Paz—IdiPAZMadridSpain
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Perucca E, Bialer M, White HS. New GABA-Targeting Therapies for the Treatment of Seizures and Epilepsy: I. Role of GABA as a Modulator of Seizure Activity and Recently Approved Medications Acting on the GABA System. CNS Drugs 2023; 37:755-779. [PMID: 37603262 PMCID: PMC10501955 DOI: 10.1007/s40263-023-01027-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2023] [Indexed: 08/22/2023]
Abstract
γ-Aminobutyric acid (GABA) is the most prevalent inhibitory neurotransmitter in the mammalian brain and has been found to play an important role in the pathogenesis or the expression of many neurological diseases, including epilepsy. Although GABA can act on different receptor subtypes, the component of the GABA system that is most critical to modulation of seizure activity is the GABAA-receptor-chloride (Cl-) channel complex, which controls the movement of Cl- ions across the neuronal membrane. In the mature brain, binding of GABA to GABAA receptors evokes a hyperpolarising (anticonvulsant) response, which is mediated by influx of Cl- into the cell driven by its concentration gradient between extracellular and intracellular fluid. However, in the immature brain and under certain pathological conditions, GABA can exert a paradoxical depolarising (proconvulsant) effect as a result of an efflux of chloride from high intracellular to lower extracellular Cl- levels. Extensive preclinical and clinical evidence indicates that alterations in GABAergic inhibition caused by drugs, toxins, gene defects or other disease states (including seizures themselves) play a causative or contributing role in facilitating or maintaning seizure activity. Conversely, enhancement of GABAergic transmission through pharmacological modulation of the GABA system is a major mechanism by which different antiseizure medications exert their therapeutic effect. In this article, we review the pharmacology and function of the GABA system and its perturbation in seizure disorders, and highlight how improved understanding of this system offers opportunities to develop more efficacious and better tolerated antiseizure medications. We also review the available data for the two most recently approved antiseizure medications that act, at least in part, through GABAergic mechanisms, namely cenobamate and ganaxolone. Differences in the mode of drug discovery, pharmacological profile, pharmacokinetic properties, drug-drug interaction potential, and clinical efficacy and tolerability of these agents are discussed.
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Affiliation(s)
- Emilio Perucca
- Department of Medicine (Austin Health), The University of Melbourne, Melbourne, VIC, Australia.
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia.
- Melbourne Brain Centre, 245 Burgundy Street, Heidelberg, VIC, 3084, Australia.
| | - Meir Bialer
- Institute of Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
- David R. Bloom Center for Pharmacy, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - H Steve White
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA, USA
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21
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Vashi V, Rosenfeld WE, Ferrari L, Kamin M. Pharmacokinetics of cenobamate as monotherapy compared with adjunctive therapy. Epilepsy Res 2023; 195:107185. [PMID: 37429218 DOI: 10.1016/j.eplepsyres.2023.107185] [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: 04/04/2023] [Revised: 06/21/2023] [Accepted: 07/03/2023] [Indexed: 07/12/2023]
Abstract
OBJECTIVE Cenobamate was approved by the US Food and Drug Administration (FDA) based on studies of adjunctive therapy in patients with focal epilepsy. To support the use of cenobamate monotherapy, this pharmacokinetic (PK)-based simulation analysis evaluated the predicted PK exposure of cenobamate when used as monotherapy versus adjunctive therapy. METHODS A population pharmacokinetic (PopPK) model of cenobamate was developed using pooled human data from eight phase 1 studies in healthy subjects or special populations, and three phase 2 and 3 studies in patients with focal seizures (N = 960). Concomitant antiseizure medications (ASMs) with a statistically significant effect on the apparent systemic clearance (CL/F) of cenobamate in the PopPK model were used to compare simulated patient plasma exposures (area under the plasma concentration vs time curve [AUC]) following monotherapy versus adjunctive therapy. Treatment equivalence between monotherapy and adjunctive therapy was concluded if the 90% confidence interval (CI) of the geometric mean AUC ratio was within 0.8-1.25. RESULTS In the PopPK model, statistically significant effects on cenobamate CL/F were shown for clobazam (decreased cenobamate CL/F by 19%) and carbamazepine (increased cenobamate CL/F by 15%); these differences were not considered clinically meaningful. Other ASMs (lacosamide, lamotrigine, levetiracetam, oxcarbazepine, topiramate, and valproate) when coadministered with cenobamate did not have significant effects on the disposition (ie, PK or efficacy) of cenobamate. The geometric mean ratio (90% CIs) of cenobamate AUC for adjunctive therapy/monotherapy was 0.87 (0.816-0.925) for adjunctive carbamazepine and 1.24 (1.147-1.339) for adjunctive clobazam. The 90% CI was within the no-effect limits (90% CIs 0.8-1.25) for adjunctive carbamazepine and partially exceeding no-effect limits for adjunctive clobazam. CONCLUSIONS Based on the results from this PopPK analysis, cenobamate monotherapy can be expected to result in comparable exposures to those that have been demonstrated to be safe and effective when used as adjunctive therapy for the treatment of focal seizures, supporting the use of cenobamate as monotherapy in these patients.
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Affiliation(s)
| | - William E Rosenfeld
- Comprehensive Epilepsy Care Center for Children and Adults, St. Louis, MO, USA
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Melnick SM, Shin Y, Glenn KJ. Anticonvulsant effects of cenobamate in chemically and electrically induced seizure models in rodents. Heliyon 2023; 9:e18920. [PMID: 37636350 PMCID: PMC10457417 DOI: 10.1016/j.heliyon.2023.e18920] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 08/29/2023] Open
Abstract
Background Cenobamate is an antiseizure medication used to treat partial-onset (focal) seizures. It is a molecule with one chiral center and a unique dual mechanism of action: enhancement of fast and slow inactivation of sodium channels with preferential inhibition of the persistent current and positive allosteric modulation of GABAA receptor-mediated ion channels. Aims/Methods Anticonvulsant effects of cenobamate (YKP3089; R-enantiomer), YKP3090 (S-enantiomer), and YKP1983 (racemate) were evaluated in chemically and electrically induced focal and generalized seizure models in rodents. The Genetic Absence Epilepsy Rat from Strasbourg (GAERS) model examined the effect of cenobamate on spike-wave seizures. Motor coordination was assessed with rotarod tests and minimal motor impairment exams. Results Early in development, cenobamate was found to have activity in focal and generalized seizure models in animals and was selected for continued development. Cenobamate prevented seizures in a dose-dependent manner, prevented seizure spread, and increased seizure threshold without potentiating seizure initiation or the development of tolerance to its anticonvulsant effects. In contrast, YKP3090 and YKP1983 were only effective against generalized tonic-clonic seizures. Cenobamate also protected mice from 6 Hz psychomotor-induced seizures. Cenobamate showed significant dose-dependent reductions in the number and cumulative duration of spike-and-wave discharges in the GAERS model. Discussion Cenobamate showed efficacy or efficacy signals in all animal models of epilepsy tested with a favorable risk-versus-benefit ratio, supporting its clinical use in the treatment of partial-onset (focal) seizures in adults and warranting further clinical research in generalized seizures and absence seizures.
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Affiliation(s)
| | - Yujin Shin
- SK Biopharmaceuticals, Co., Ltd., Seongnam, Gyeonggi, Republic of Korea
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23
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Rosenfeld WE, Ferrari L, Kerr WT, Sperling MR. Sudden unexpected death in epilepsy during cenobamate clinical development. Epilepsia 2023; 64:2108-2115. [PMID: 37219391 DOI: 10.1111/epi.17662] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/18/2023] [Accepted: 05/22/2023] [Indexed: 05/24/2023]
Abstract
OBJECTIVE We assessed mortality, sudden unexpected death in epilepsy (SUDEP), and standardized mortality ratio (SMR) among adults treated with cenobamate during the cenobamate clinical development program. METHODS We retrospectively analyzed deaths among all adults with uncontrolled focal (focal to bilateral tonic-clonic [FBTC], focal impaired awareness, focal aware) or primary generalized tonic-clonic (PGTC) seizures who received ≥1 dose of adjunctive cenobamate in completed and ongoing phase 2 and 3 clinical studies. In patients with focal seizures from completed studies, median baseline seizure frequencies ranged from 2.8 to 11 seizures per 28 days and median epilepsy duration ranged from 20 to 24 years. Total person-years included all days that a patient received cenobamate during completed studies or up to June 1, 2022, for ongoing studies. All deaths were evaluated by two epileptologists. All-cause mortality and SUDEP rates were expressed per 1000 person-years. RESULTS A total of 2132 patients (n = 2018 focal epilepsy; n = 114 idiopathic generalized epilepsy) were exposed to cenobamate for 5693 person-years. Approximately 60% of patients with focal seizures and all patients in the PGTC study had tonic-clonic seizures. A total of 23 deaths occurred (all in patients with focal epilepsy), for an all-cause mortality rate of 4.0 per 1000 person-years. Five cases of definite or probable SUDEP were identified, for a rate of .88 per 1000 person-years. Of the 23 overall deaths, 22 patients (96%) had FBTC seizures, and all 5 of the SUDEP patients had a history of FBTC seizures. The duration of exposure to cenobamate for patients with SUDEP ranged from 130 to 620 days. The SMR among cenobamate-treated patients in completed studies (5515 person-years of follow-up) was 1.32 (95% confidence interval [CI] .84-2.0), which was not significantly different from the general population. SIGNIFICANCE These data suggest that effective long-term medical treatment with cenobamate may reduce excess mortality associated with epilepsy.
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Affiliation(s)
- William E Rosenfeld
- Comprehensive Epilepsy Care Center for Children and Adults, St. Louis, Missouri, USA
| | | | - Wesley T Kerr
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael R Sperling
- Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Rissardo JP, Fornari Caprara AL. Cenobamate (YKP3089) and Drug-Resistant Epilepsy: A Review of the Literature. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1389. [PMID: 37629678 PMCID: PMC10456719 DOI: 10.3390/medicina59081389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/08/2023] [Accepted: 07/24/2023] [Indexed: 08/27/2023]
Abstract
Cenobamate (CNB), ([(R)-1-(2-chlorophenyl)-2-(2H-tetrazol-2-yl)ethyl], is a novel tetrazole alkyl carbamate derivative. In November 2019, the Food and Drug Administration approved Xcopri®, marketed by SK Life Science Inc., (Paramus, NJ, USA) for adult focal seizures. The European Medicines Agency approved Ontozry® by Arvelle Therapeutics Netherlands B.V.(Amsterdam, The Neatherlands) in March 2021. Cenobamate is a medication that could potentially change the perspectives regarding the management and prognosis of refractory epilepsy. In this way, this study aims to review the literature on CNB's pharmacological properties, pharmacokinetics, efficacy, and safety. CNB is a highly effective drug in managing focal onset seizures, with more than twenty percent of individuals with drug-resistant epilepsy achieving seizure freedom. This finding is remarkable in the antiseizure medication literature. The mechanism of action of CNB is still poorly understood, but it is associated with transient and persistent sodium currents and GABAergic neurotransmission. In animal studies, CNB showed sustained efficacy and potency in the 6 Hz test regardless of the stimulus intensity. CNB was revealed to be the most cost-effective drug among different third-generation antiseizure medications. Also, CNB could have neuroprotective effects. However, there are still concerns regarding its potential for abuse and suicidality risk, which future studies should clearly assess, after which protocols should be changed. The major drawback of CNB therapy is the slow and complex titration and maintenance phases preventing the wide use of this new agent in clinical practice.
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Affiliation(s)
- Jamir Pitton Rissardo
- Medicine Department, Federal University of Santa Maria, Santa Maria 97105-900, Brazil;
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25
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Friedo AL, Greshake B, Makridis KL, Straub HB. Cenobamate significantly improves seizure control in intellectually disabled patients with drug-resistant epilepsy and allows drug load reduction. Front Neurol 2023; 14:1209487. [PMID: 37528853 PMCID: PMC10390252 DOI: 10.3389/fneur.2023.1209487] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/22/2023] [Indexed: 08/03/2023] Open
Abstract
Introduction Epilepsy patients with intellectual disability often suffer from drug-resistant epilepsy (DRE), which severely affects patients' quality of life. Cenobamate (CNB) is a recently approved novel and effective ASM that can achieve high rates of seizure freedom in previously drug-resistant patients. Methods We performed a retrospective data analysis of the first patients treated with CNB at a single center. Outcome and treatment response were assessed at two different time points, and ASM burden was calculated. Results A 12 patients (7 males and 5 females) began treatment at a median age of 43 years, six of whom had developmental and epileptic encephalopathies. Prior to treatment with CNB, patients had tried a median of 13 different ASM. At the start of CNB therapy, patients were taking a median of 3 ASM. Treatment outcomes were available for 11 patients. After the first follow-up period (median 9 months), 55% of patients showed a significant seizure reduction of more than 50%, with three patients showing a reduction of more than 75% (27%). One patient achieved complete seizure freedom, while one patient did not respond to treatment. These response rates were consistently maintained at second follow-up after a median of 22 months. Ten patients (83%) reported adverse events (AE), the most common of which were dizziness and fatigue. No cases of drug reactions with eosinophilia and systemic symptoms (DRESS) were observed. The majority of AEs were mild and resolved over time. In addition, most patients were able to reduce their concomitant ASM. Discussion Cenobamate has been shown to be an effective ASM in patients with DRE and in patients with intellectual disabilities. After more than 1 year of treatment with CNB, close monitoring and management of drug-drug interactions may reduce enzyme-inducing ASMs and lead to better long-term outcomes. With CNB treatment, many patients can achieve a reduced overall drug burden while maintaining a reduction in seizures.
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Affiliation(s)
| | | | - Konstantin L. Makridis
- Department of Pediatric Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Epilepsy Center for Children and Adolescents, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Institute of Cell Biology and Neurobiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
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Pitton Rissardo J, Fornari Caprara AL, Casares M, Skinner HJ, Hamid U. Antiseizure Medication-Induced Alopecia: A Literature Review. MEDICINES (BASEL, SWITZERLAND) 2023; 10:35. [PMID: 37367730 DOI: 10.3390/medicines10060035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/28/2023]
Abstract
Background: Adverse effects of antiseizure medications (ASMs) remain one of the major causes of non-adherence. Cosmetic side effects (CSEs) are among the most commonly reported side effects of ASMs. In this context, alopecia is one of the CSEs that has a high intolerance rate leading to poor therapeutical compliance. Methods: We performed a literature review concerning alopecia as a secondary effect of ASMs. Results: There are 1656 individuals reported with ASM-induced alopecia. Valproate (983), lamotrigine (355), and carbamazepine (225) have been extensively reported. Other ASMs associated with alopecia were cenobamate (18), levetiracetam (14), topiramate (13), lacosamide (7), vigabatrin (6), phenobarbital (5), gabapentin (5), phenytoin (4), pregabalin (4), eslicarbazepine (3), brivaracetam (2), clobazam (2), perampanel (2), trimethadione (2), rufinamide (2), zonisamide (2), primidone (1), and tiagabine (1). There were no reports of oxcarbazepine and felbamate with drug-induced alopecia. Hair loss seen with ASMs was diffuse and non-scarring. Telogen effluvium was the most common cause of alopecia. A characteristic feature was the reversibility of alopecia after ASM dose adjustment. Conclusions: Alopecia should be considered one important adverse effect of ASMs. Patients reporting hair loss with ASM therapy should be further investigated, and specialist consultation is recommended.
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Affiliation(s)
- Jamir Pitton Rissardo
- Medicine Department, Federal University of Santa Maria, Santa Maria 97105-900, Brazil
| | | | - Maritsa Casares
- AdventHealth Orlando Neuroscience Institute, 615 E Princeton Street, Suite 540, Orlando, FL 32803, USA
| | - Holly J Skinner
- AdventHealth Epilepsy at Orlando, 615 E Princeton Street, Suite 540, Orlando, FL 32803, USA
| | - Umair Hamid
- Department of Neurology, College of Medicine, University of Illinois, Peoria, IL 61605, USA
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Klein P, Krauss GL, Steinhoff BJ, Devinsky O, Sperling MR. Failure to use new breakthrough treatments for epilepsy. Epilepsia 2023; 64:1458-1465. [PMID: 36855241 DOI: 10.1111/epi.17564] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/29/2023] [Accepted: 02/27/2023] [Indexed: 03/02/2023]
Abstract
Despite the approval of ~20 additional antiseizure medications (ASMs) since the 1980s, one-third of epilepsy patients experience seizures despite therapy. Drug-resistant epilepsy (DRE) is associated with cognitive and psychiatric comorbidities, socioeconomic impairment, injuries, and a 9.3-13.4 times higher mortality rate than in seizure-free patients. Improved seizure control can reduce morbidity and mortality. Two new ASMs were launched in the United States in 2020: cenobamate for focal epilepsy in adults and fenfluramine for Dravet syndrome (DS). They offer markedly improved efficacy. Cenobamate achieved 21% seizure freedom with the highest dose and decreased tonic-clonic seizures by 93% during maintenance treatment in a randomized clinical trial (RCT). In long-term, open-label studies, 10%-36% of patients were seizure-free for a median duration of ~30-45 months. Fenfluramine treatment in DS reduced convulsive seizure frequency by 56% over placebo at the highest dose, with 8% of patients free of convulsive seizures, and 25% with only one convulsive seizure over 14 weeks. These results were sustained for up to 3 years in open-label extension studies. Mortality was reduced 5-fold. These results are superior to all other approved ASMs, placing these two drugs among the most effective antiseizure therapies. The adverse event profiles resemble those of other ASMs. Despite greater efficacy and similar toxicity, these medications are infrequently used. Two years after US market entry, < 5% of either adults with focal DRE or patients with DS were treated with either cenobamate or fenfluramine. We believe this is a failure of our medical system, resulting from limited knowledge about these drugs stemming partly from the separation of academia from industry; restrictions to access created by health care payors, hospitals, and regulatory agencies; and insufficient post-launch information about the efficacy and safety of these ASMs.
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Affiliation(s)
- Pavel Klein
- Mid-Atlantic Epilepsy and Sleep Center, Bethesda, Maryland, USA
| | - Gregory L Krauss
- Johns Hopkins University School of Medicine, Department of Neurology, Baltimore, Maryland, USA
| | - Bernhard J Steinhoff
- Epilepsiezentrum Kork, Kehl-Kork, Germany and Medical Faculty, Albert-Ludwigs University, Freiburg, Germany
| | - Orrin Devinsky
- NYU Langone School of Medicine, Department of Neurology, New York, New York, USA
| | - Michael R Sperling
- Thomas Jefferson University, Department of Neurology, Philadelphia, Pennsylvania, USA
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Peña-Ceballos J, Moloney PB, Munteanu T, Doyle M, Colleran N, Liggan B, Breen A, Murphy S, El-Naggar H, Widdess-Walsh P, Delanty N. Adjunctive cenobamate in highly active and ultra-refractory focal epilepsy: A "real-world" retrospective study. Epilepsia 2023; 64:1225-1235. [PMID: 36790345 DOI: 10.1111/epi.17549] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 02/12/2023] [Accepted: 02/13/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVE Recent clinical trials have shown that cenobamate substantially improves seizure control in focal-onset drug-resistant epilepsy (DRE). However, little is known about cenobamate's performance in highly active (≥20 seizures/month) and ultra-refractory focal epilepsy (≥6 failed epilepsy treatments, including antiseizure medications [ASMs], epilepsy surgery, and vagus nerve stimulation). Here, we studied cenobamate's efficacy and tolerability in a "real-world" severe DRE cohort. METHODS We conducted a single-center retrospective analysis of consecutive adults treated with cenobamate between October 2020 and September 2022. All patients received cenobamate through an Early Access Program. Cenobamate retention, seizure outcomes, treatment-emergent adverse events, and adjustments to concomitant ASMs were analyzed. RESULTS Fifty-seven patients received cenobamate for at least 3 months (median duration, 11 months). The median cenobamate dose was 250 mg/day (range 75-350 mg). Baseline demographics were consistent with highly active (median seizure frequency, 60/month) and ultra-refractory epilepsy (median previously failed ASMs, nine). Most (87.8%) had prior epilepsy surgery and/or vagus nerve stimulation. Six patients stopped cenobamate due to lack of efficacy and/or adverse events. One patient died from factors unrelated to cenobamate. Among patients who continued cenobamate, three achieved seizure freedom (5.3% of cohort), 24 had a 75%-99% reduction in seizures (42.1% of cohort), and 16 had a 50%-74% reduction (28.1% of cohort). Cenobamate led to abolition of focal to bilateral tonic-clonic seizures in 55.6% (20/36) of patients. Among treatment responders, 67.4% (29/43) were treated with cenobamate doses of ≥250 mg/day. Three-fourths of patients reported at least one side-effect, most commonly fatigue and somnolence. Adverse events most commonly emerged at cenobamate doses of ≥250 mg/day. Side-effects were partially manageable by reducing the overall ASM burden, most often clobazam, eslicarbazepine, and perampanel. SIGNIFICANCE Patients with highly active and ultra-refractory focal epilepsy experienced meaningful seizure outcomes on cenobamate. Emergence of adverse events at doses above 250 mg/day may limit the potential for further improvements in seizure control at higher cenobamate doses.
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Affiliation(s)
| | - Patrick B Moloney
- Department of Neurology, Beaumont Hospital, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- FutureNeuro, the Science Foundation Ireland Research Centre for Chronic and Rare Neurological Diseases, Dublin, Ireland
| | - Tudor Munteanu
- Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | - Michael Doyle
- Department of Neurology, Beaumont Hospital, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- FutureNeuro, the Science Foundation Ireland Research Centre for Chronic and Rare Neurological Diseases, Dublin, Ireland
| | - Niamh Colleran
- Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | - Brenda Liggan
- Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | - Annette Breen
- Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | - Sinead Murphy
- Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | - Hany El-Naggar
- Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | | | - Norman Delanty
- Department of Neurology, Beaumont Hospital, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- FutureNeuro, the Science Foundation Ireland Research Centre for Chronic and Rare Neurological Diseases, Dublin, Ireland
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Löscher W, White HS. Animal Models of Drug-Resistant Epilepsy as Tools for Deciphering the Cellular and Molecular Mechanisms of Pharmacoresistance and Discovering More Effective Treatments. Cells 2023; 12:cells12091233. [PMID: 37174633 PMCID: PMC10177106 DOI: 10.3390/cells12091233] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/28/2023] [Accepted: 04/18/2023] [Indexed: 05/15/2023] Open
Abstract
In the last 30 years, over 20 new anti-seizure medicines (ASMs) have been introduced into the market for the treatment of epilepsy using well-established preclinical seizure and epilepsy models. Despite this success, approximately 20-30% of patients with epilepsy have drug-resistant epilepsy (DRE). The current approach to ASM discovery for DRE relies largely on drug testing in various preclinical model systems that display varying degrees of ASM drug resistance. In recent years, attempts have been made to include more etiologically relevant models in the preclinical evaluation of a new investigational drug. Such models have played an important role in advancing a greater understanding of DRE at a mechanistic level and for hypothesis testing as new experimental evidence becomes available. This review provides a critical discussion of the pharmacology of models of adult focal epilepsy that allow for the selection of ASM responders and nonresponders and those models that display a pharmacoresistance per se to two or more ASMs. In addition, the pharmacology of animal models of major genetic epilepsies is discussed. Importantly, in addition to testing chemical compounds, several of the models discussed here can be used to evaluate other potential therapies for epilepsy such as neurostimulation, dietary treatments, gene therapy, or cell transplantation. This review also discusses the challenges associated with identifying novel therapies in the absence of a greater understanding of the mechanisms that contribute to DRE. Finally, this review discusses the lessons learned from the profile of the recently approved highly efficacious and broad-spectrum ASM cenobamate.
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Affiliation(s)
- Wolfgang Löscher
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine, Bünteweg 17, 30559 Hannover, Germany
- Center for Systems Neuroscience, 30559 Hannover, Germany
| | - H Steve White
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA 98195, USA
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Osborn M, Abou-Khalil B. The cenobamate-clobazam interaction- evidence of synergy in addition to pharmacokinetic interaction. Epilepsy Behav 2023; 142:109156. [PMID: 37037060 DOI: 10.1016/j.yebeh.2023.109156] [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: 01/09/2023] [Revised: 02/21/2023] [Accepted: 02/21/2023] [Indexed: 04/12/2023]
Abstract
OBJECTIVES Report insights into the pharmacokinetic and pharmacodynamic interaction between cenobamate (CNB) and clobazam (CLB), derived from data in patients enrolled at our center in a global multicenter open-label safety study of CNB. MATERIALS & METHODS Patients in this study either took CLB at baseline (n = 6) or had CLB added after CNB titration to maximal dose (n = 5) in addition to other antiseizure medications. Clobazam was always administered as a single bedtime dose. Random serum concentrations of CLB and N-desmethylclobazam (N-CLB) were obtained. RESULTS Baseline daily CLB doses were 20-50 mg. Sedation began in the six baseline CLB patients at CNB doses of 25-100 mg. The N-CLB/ CLB ratio increased proportionally to the CNB dose. CLB was stopped in all six patients, five of whom were ≥50% responders. Seizure control deteriorated after stopping CLB, with only one remaining responder. Clobazam was restarted at 5 mg/d in five of the six patients. At the last follow-up, four of these patients were continuing CLB; two were seizure-free and 2 were ≥50% responders. Among the five patients that added 5 mg/d CLB de novo, three were responders. All patients were still on CNB at the end of the study. DISCUSSION Data suggest starting CLB dose reduction at CNB doses of 25-100 mg/d. Due to possible synergy, the addition of low-dose CLB could be considered in patients with incomplete response to CNB.
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Affiliation(s)
- Melissa Osborn
- Department of Neurology, Vanderbilt University Medical Center, 1161 21st Avenue South, A0118 MCN, Nashville, TN 37232, USA.
| | - Bassel Abou-Khalil
- Department of Neurology, Vanderbilt University Medical Center, 1161 21st Avenue South, A0118 MCN, Nashville, TN 37232, USA.
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Agashe S, Worrell G, Britton J, Noe K, Ritaccio A, Wirrell EC, Nickels KC, Cascino GD, Burkholder D. Cenobamate in Generalized Epilepsy and Combined Generalized and Focal Epilepsy. Neurol Clin Pract 2023; 13:e200133. [PMID: 37064578 PMCID: PMC10103690 DOI: 10.1212/cpj.0000000000200133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 11/17/2022] [Indexed: 02/17/2023]
Abstract
Background and ObjectivesCenobamate (CNB) is a United States Food and Drug Administration–approved antiseizure medication (ASM) for focal-onset seizures; however, its potential clinical effectiveness as a broad-spectrum ASM is not established. CNB has a proposed dual mechanism of action with preferential blockade of persistent sodium currents and positive allosteric modulation of the γ-aminobutyric acid-A (GABA-A) receptor. We evaluated the efficacy of CNB in drug refractory patients with genetic generalized epilepsies (GGE) or combined generalized and focal epilepsies (CGFE), including developmental and epileptic encephalopathies.MethodsWe performed a retrospective review and identified the following: cohort 1 (n = 4) with GGE, of which 2 patients had idiopathic generalized epilepsy, and cohort 2 with CGFE (n = 9), of which 4 patients had Lennox-Gastaut syndrome and 1 had Dravet syndrome.ResultsIn cohort 1, all 3 patients with frequent generalized tonic-clonic seizures (GTCs) had a greater than 50% reduction in GTCs. In cohort 2, reduction in both generalized and focal-onset seizures was noted. In these groups together, the mean reduction of all seizure types was 58%, and ≥50% responder rate was 70% (SD = ±34.16, median = 50%). No worsening of generalized-onset seizures occurred in either cohort. Seventy-seven percent of patients experienced side effects, warranting a modification of treatment managed by slower titration, dose reduction of CNB, or discontinuing other ASMs.DiscussionIn our retrospective case series, CNB seems to be an effective ASM for patients with drug-resistant GGE and CGFE. The ongoing CNB trial assessing effectiveness for primary GTCs will provide more data on generalized-onset seizures.Classification of EvidenceThis study provides Class IV evidence that CNB in generalized epilepsy and combined generalized and focal epilepsy reduces seizure frequency.
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Affiliation(s)
- Shruti Agashe
- Department of Neurology (SA, GW, JB, ECW, KCN, GDC, DB), Mayo Clinic, Rochester, MN; Department of Neurology (KN), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (AR), Mayo Clinic, Jacksonville, FL
| | - Gregory Worrell
- Department of Neurology (SA, GW, JB, ECW, KCN, GDC, DB), Mayo Clinic, Rochester, MN; Department of Neurology (KN), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (AR), Mayo Clinic, Jacksonville, FL
| | - Jeffrey Britton
- Department of Neurology (SA, GW, JB, ECW, KCN, GDC, DB), Mayo Clinic, Rochester, MN; Department of Neurology (KN), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (AR), Mayo Clinic, Jacksonville, FL
| | - Katherine Noe
- Department of Neurology (SA, GW, JB, ECW, KCN, GDC, DB), Mayo Clinic, Rochester, MN; Department of Neurology (KN), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (AR), Mayo Clinic, Jacksonville, FL
| | - Anthony Ritaccio
- Department of Neurology (SA, GW, JB, ECW, KCN, GDC, DB), Mayo Clinic, Rochester, MN; Department of Neurology (KN), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (AR), Mayo Clinic, Jacksonville, FL
| | - Elaine C Wirrell
- Department of Neurology (SA, GW, JB, ECW, KCN, GDC, DB), Mayo Clinic, Rochester, MN; Department of Neurology (KN), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (AR), Mayo Clinic, Jacksonville, FL
| | - Katherine C Nickels
- Department of Neurology (SA, GW, JB, ECW, KCN, GDC, DB), Mayo Clinic, Rochester, MN; Department of Neurology (KN), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (AR), Mayo Clinic, Jacksonville, FL
| | - Gregory D Cascino
- Department of Neurology (SA, GW, JB, ECW, KCN, GDC, DB), Mayo Clinic, Rochester, MN; Department of Neurology (KN), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (AR), Mayo Clinic, Jacksonville, FL
| | - David Burkholder
- Department of Neurology (SA, GW, JB, ECW, KCN, GDC, DB), Mayo Clinic, Rochester, MN; Department of Neurology (KN), Mayo Clinic, Scottsdale, AZ; and Department of Neurology (AR), Mayo Clinic, Jacksonville, FL
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Carlson JM, Molyneaux BJ, Lee JW. Safe Use of Cenobamate in Super Refractory Status Epilepticus: A Case Series. Neurohospitalist 2023; 13:169-172. [PMID: 37064924 PMCID: PMC10091428 DOI: 10.1177/19418744221147083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023] Open
Abstract
Cenobamate is an effective new adjunctive antiseizure medication (ASM) for treatment resistant focal epilepsy. It has broad spectrum anticonvulsant activity and may be a useful medication for super refractory status epilepticus (SRSE), but has not yet been studied in generalized seizures or an inpatient setting. Here we describe 2 SRSE cases where cenobamate was added safely to other treatments. It was uptitrated slowly to reduce the risk of hypersensitivity reactions which have been observed previously with rapid increasing dosages. Both patients achieved seizure control and liberation from intensive care. They have remained seizure free with continued treatment and have not experienced any side effects attributable to cenobamate. Cenobamate warrants further examination in patients with refractory status epilepticus.
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Affiliation(s)
- Julia M. Carlson
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | | | - Jong Woo Lee
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
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Abstract
PURPOSE OF REVIEW Epilepsy affects 70 million people worldwide and is a significant cause of morbidity and early mortality. The mainstay of therapy is oral medications. Epilepsy drug development is escalating, driven by continued drug resistance in up to a third of epilepsy patients. Treatment development now focuses on discovery of novel mechanisms of action and syndrome-specific therapies. RECENT FINDINGS Difficult-to-treat epilepsy related to conditions including tuberous sclerosis complex (TSC), Lennox Gastaut syndrome (LGS) and Dravet syndrome (DS) have been the target of recent developments. Disease-modifying therapy for epilepsy related to TSC with vigabatrin at onset of first electroencephalographic epileptiform changes, rather than after first clinical seizure, has demonstrated strongly positive seizure and developmental outcomes. Fenfluramine, approved for DS and, more recently, LGS, has robust data supporting efficacy, safety/tolerability, as well as mortality, quality of life and cognitive function. Rescue therapy has expanded to include better tolerated benzodiazepines in the form of nasal midazolam and valium. Cenobamate, a first-in-class inactivator of the persistent voltage-gated sodium channel and approved for adult partial onset epilepsy, has exceptional efficacy and tolerability and will be expanded to children and to generalized onset epilepsy in adults. SUMMARY The repertoire of available and developmental therapies for epilepsy is rapidly expanding, and now includes disease-modifying vigabatrin in TSC and agents with extraordinary efficacy, fenfluramine and cenobamate.
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Affiliation(s)
- Amanda W Pong
- Mid-Atlantic Epilepsy and Sleep Center, Mid-Atlantic Neurological Institute, Bethesda, Maryland, USA
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34
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Hoppe B, Weber Y, Wolking S. [Interactions between anti-seizure medications and recommendations for combination treatment]. DER NERVENARZT 2023; 94:149-158. [PMID: 36695895 DOI: 10.1007/s00115-022-01434-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/16/2022] [Indexed: 01/26/2023]
Abstract
Pharmacotherapy is the most important pillar in the treatment of epilepsies. In approximately 50% of epilepsy patients monotherapy with anti-seizure medications (ASM) is insufficient. The knowledge of specific drug interactions in combination therapies is essential to recognize and avoid adverse side effects up to relevant therapy risks, including loss of efficiency and intoxication. Interactions can be of a pharmacokinetic or pharmacodynamic nature. Some effects of interactions in combination therapies can also be advantageous. Therapeutic drug monitoring in serum is not necessary for all ASMs and should be used rationally: however, it should be performed consistently if the indications are present. This review article provides fundamental knowledge about the most relevant interactions between ASMs and the indications for therapeutic drug monitoring.
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Affiliation(s)
- Barbara Hoppe
- Sektion Epileptologie, Klinik für Neurologie, Universitätsklinikum Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.
| | - Yvonne Weber
- Sektion Epileptologie, Klinik für Neurologie, Universitätsklinikum Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.,Abteilung Neurologie mit Schwerpunkt Epileptologie, Hertie Institut für Klinische Hirnforschung, Universität Tübingen, Tübingen, Deutschland
| | - Stefan Wolking
- Sektion Epileptologie, Klinik für Neurologie, Universitätsklinikum Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
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35
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Laskier V, Agyei-Kyeremateng KK, Eddy AE, Patel D, Mulheron S, James S, Thomas RH, Sander JW. Cost-effectiveness of cenobamate for focal seizures in people with drug-resistant epilepsy. Epilepsia 2023; 64:843-856. [PMID: 36625423 DOI: 10.1111/epi.17506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/06/2023] [Accepted: 01/06/2023] [Indexed: 01/11/2023]
Abstract
OBJECTIVE This study was undertaken to estimate the cost-effectiveness of add-on cenobamate in the UK when used to treat drug-resistant focal seizures in adults who are not adequately controlled with at least two prior antiseizure medications, including at least one used adjunctively. METHODS We estimated the cost per quality-adjusted life-year (QALY) for cenobamate compared to brivaracetam, eslicarbazepine, lacosamide, and perampanel in the UK National Health Service over a lifetime time horizon. We used a Markov cohort structure to determine response to treatment, using pooled data from three long-term studies of cenobamate. A network meta-analysis informed the likelihood of response to therapy with brivaracetam, eslicarbazepine, lacosamide, and perampanel relative to cenobamate. Once individuals discontinued treatment, they transitioned to subsequent treatment health states, including other antiseizure medicines, surgery, and vagus nerve stimulation. Costs included treatment, administration, routine monitoring, event management, and adverse events. Published evidence and expert opinion informed the likelihood of response to subsequent treatments, associated adverse events, and costs. Utility data were based on Short-Form six-dimension form utility. Discounting was applied at 3.5% per annum as per National Institute for Health and Care Excellence guidance. Uncertainty was explored through deterministic and probabilistic sensitivity analyses. RESULTS In the base case, cenobamate led to cost savings of £51 967 (compared to brivaracetam), £21 080 (compared to eslicarbazepine), £33 619 (compared to lacosamide), and £28 296 (compared to perampanel) and increased QALYs of 1.047 (compared to brivaracetam), 0.598 (compared to eslicarbazepine), 0.776 (compared to lacosamide), and 0.703 (compared to perampanel) per individual over a lifetime time horizon. Cenobamate also dominated the four drugs across most sensitivity analyses. Differences were due to reduced seizure frequency with cenobamate relative to comparators. SIGNIFICANCE Cenobamate improved QALYs and was less costly than brivaracetam, eslicarbazepine, lacosamide, and perampanel. Therefore, cenobamate may be considered as a cost-effective adjunctive antiseizure medication for people with drug-resistant focal seizures.
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Affiliation(s)
| | | | | | | | | | | | - Rhys H Thomas
- Department of Neurology, Royal Victoria Infirmary, Newcastle Upon Tyne, UK.,Translational and Clinical Research Institute, Newcastle, UK
| | - Josemir W Sander
- UCL Queen Square Institute of Neurology, London, UK.,Chalfont Centre for Epilepsy, Chalfont St Peter, UK.,Stichting Epilepsie Instellingen Nederland, Heemstede, The Netherlands.,Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
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36
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Lemus HN, Sarkis RA. Epilepsy care in nursing facilities: Knowledge gaps and opportunities. Epilepsy Behav 2023; 138:108997. [PMID: 36442262 DOI: 10.1016/j.yebeh.2022.108997] [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: 08/15/2022] [Revised: 11/08/2022] [Accepted: 11/09/2022] [Indexed: 11/27/2022]
Abstract
Epilepsy in the elderly is a complex disease, often underdiagnosed, and inadequately treated. It requires a multi-disciplinary approach and care coordination especially if the patient resides in a nursing facility. Episodes of loss of consciousness falls, or amnestic events in those living in a nursing facility require a detailed description and an urgent assessment to rule out an epileptic seizure. Prompt recognition of seizures and the implementation of treatment protocols in those with recurrent seizures are needed to prevent unnecessary emergency visits. Although there is a myriad of antiseizure medications (ASM) to treat seizures, clinicians should be aware of common interactions, side effects, and changes in pharmacodynamics with age. There is a limited number of ASMs that have been properly studied in clinical trials to assess tolerability and efficacy in the elderly, and an over-reliance on enzyme-inducing ASMs. Strategies to improve the knowledge of health care providers include electronic resources, treatment protocols, and improving awareness of the efficacy, drug-drug interaction, and short-term and long-term monitoring of ASM side effects.
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Affiliation(s)
| | - Rani A Sarkis
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
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37
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Song WS, Cho YS, Oh SP, Yoon SH, Kim YS, Kim MH. Cognitive and behavioral effects of the anti-epileptic drug cenobamate (YKP3089) and underlying synaptic and cellular mechanisms. Neuropharmacology 2022; 221:109292. [DOI: 10.1016/j.neuropharm.2022.109292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 09/30/2022] [Accepted: 10/09/2022] [Indexed: 11/08/2022]
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38
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Makridis KL, Friedo AL, Kellinghaus C, Losch FP, Schmitz B, Boßelmann C, Kaindl AM. Successful treatment of adult Dravet syndrome patients with cenobamate. Epilepsia 2022; 63:e164-e171. [PMID: 36176237 DOI: 10.1111/epi.17427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 01/11/2023]
Abstract
Dravet syndrome (DS) is a rare, drug-resistant, severe developmental and epileptic encephalopathy caused by pathogenic variants in the α subunit of the voltage-gated sodium channel gene SCN1A. Hyperexcitability in DS results from loss of function in inhibitory interneurons. Thus sodium channel blockers are usually contraindicated in patients with DS as they may lead to disease aggravation. Cenobamate (CNB) is a novel antiseizure medication (ASM) with promising rates of seizure freedom in patients with focal-onset, drug-resistant epilepsy. CNB blocks persistent sodium currents by promoting the inactive states of sodium channels. In a multi-center study, we analyzed retrospectively the effect of an add-on therapy of CNB in adult patients with DS. We report four adult patients with DS in whom the use of CNB resulted in a significant seizure reduction of more than 80%, with a follow-up of up to 542 days. CNB was the first drug in these patients that resulted in a long-lasting and significant seizure reduction. No severe adverse events occurred. We highlight CNB as an ASM that may lead to a clinically meaningful reduction of seizure frequency in adult patients with DS. It is unclear, however, if all patients with DS benefit, requiring further investigation and functional experiments.
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Affiliation(s)
- Konstantin L Makridis
- Department of Pediatric Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Chronically Sick Children, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Institute of Cell and Neurobiology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Epilepsy Center for Children and Adolescents, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Anna-Lena Friedo
- Epilepsy Center Berlin-Brandenburg, Epilepsieklinik Tabor, Bernau, Germany
| | | | | | - Bettina Schmitz
- Department of Neurology, Vivantes Humboldt-Klinikum, Berlin, Germany
| | - Christian Boßelmann
- Department of Neurology and Epileptology, Hertie Institute for Clinical Brain Research, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Angela M Kaindl
- Department of Pediatric Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Chronically Sick Children, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Institute of Cell and Neurobiology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Epilepsy Center for Children and Adolescents, Charité - Universitätsmedizin Berlin, Berlin, Germany
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39
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Schuetz E, Wagner K, Metternich B, Papadopoulou G, Kravalis K, Heers M, Martínez-Lizana E, Castillo-Rodriguez M, Altenmüller DM, Schulze-Bonhage A, Hirsch M. Effects of cenobamate on cognitive performance of epilepsy patients. Seizure 2022; 102:129-133. [DOI: 10.1016/j.seizure.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/29/2022] [Accepted: 10/03/2022] [Indexed: 10/31/2022] Open
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40
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Kerr WT, Brandt C, Ngo LY, Patten A, Cheng JY, Kramer L, French JA. Time to exceed pre-randomization monthly seizure count for perampanel in participants with primary generalized tonic-clonic seizures: A potential clinical end point. Epilepsia 2022; 63:2994-3004. [PMID: 36106379 PMCID: PMC9828687 DOI: 10.1111/epi.17411] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/13/2022] [Accepted: 09/13/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To evaluate the exploratory time to exceed pre-randomization seizure count (T-PSC) in the determination of efficacy of adjunctive perampanel in participants with primary generalized tonic-clonic (PGTC) seizures in generalized-onset epilepsy. METHODS In this multicenter, double-blind study (ClinicalTrials.gov identifier: NCT01393743), participants ≥12 years of age with treatment-resistant idiopathic generalized epilepsy were randomized to receive placebo or adjunctive perampanel (≤8 mg/day) across a 17-week double-blind treatment phase (4-week titration; 13-week maintenance). We evaluated the pre-planned exploratory end point of the T-PSC using a Kaplan-Meier analysis. We also re-evaluated the correspondence of the primary end points of median percent seizure frequency change (MPC) and 50% responder rate (50RR) calculated at T-PSC and at the end of the trial. RESULTS The exploratory end point of median T-PSC on placebo was 43 days and >120 days on perampanel (log-rank p < .001). The primary end points calculated at T-PSC did not differ significantly from the end points at the end of the trial (MPC -31% vs -42% at T-PSC; 50RR 32% vs 51% at T-PSC). After T-PSC was reached, participants had a median (interquartile range) of 5 (3-13) additional seizures on placebo and 5 (2-10) on perampanel. SIGNIFICANCE The exploratory end point of T-PSC demonstrated the effectiveness of perampanel despite a shorter duration of monitoring. The seizures that occurred after T-PSC did not influence the conclusions of the trial; therefore, T-PSC may be a viable alternative to traditional trial end points that reduces the risk to participants.
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Affiliation(s)
- Wesley T. Kerr
- Department of NeurologyUniversity of MichiganAnn ArborMichiganUSA
| | - Christian Brandt
- Bethel Epilepsy CenterUniversity Hospital for EpileptologyBielefeldGermany
| | - Leock Y. Ngo
- Department of NeurologyEisai Inc.NutleyNew JerseyUSA
| | | | | | - Lynn Kramer
- Department of NeurologyEisai Inc.NutleyNew JerseyUSA
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Villani F, Cianci V, Di Bonaventura C, Di Gennaro G, Galimberti CA, Guerrini R, La Neve A, Mecarelli O, Pietrafusa N, Specchio N, Vigevano F, Perucca E. Use of cenobamate for the treatment of focal epilepsy: an Italian expert opinion paper. Expert Rev Neurother 2022; 22:935-940. [PMID: 36662573 DOI: 10.1080/14737175.2023.2171291] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Cenobamate is a new antiseizure medication (ASM) recently introduced in the USA for the treatment of adults with focal-onset seizures. In March 2021, the European Commission authorized its use for the adjunctive treatment of focal-onset seizures with or without secondary generalization (focal seizures with or without progression to bilateral tonic-clonic seizures, according to current ILAE terminology) in adults with epilepsy not adequately controlled despite the treatment with at least two ASMs. AREAS COVERED This review summarizes the mechanism of action, efficacy, and safety of Cenobamate. The authors provide their expert opinions on the use of this drug. EXPERT OPINION The aim of this paper is to report on the Italian preliminary experience with the use of cenobamate, focusing on treatment goals, optimal dosing and titration schedules, strategies to minimize adverse effects, and identification of suitable candidates for treatment. There was agreement that slow titration may improve tolerability, and that clinically significant benefit can be achieved in many patients at relatively low doses. A favorable response to relatively low doses of cenobamate could be an early predictor of ultimate responsiveness. Overall, cenobamate is a welcome new treatment for adults with focal seizures resistant to conventional ASMs.
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Affiliation(s)
- Flavio Villani
- Division of Clinical Neurophysiology and Epilepsy Center, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Vittoria Cianci
- Regional Epilepsy Centre, Great Metropolitan Hospital, Bianchi-Melacrino Morelli, Reggio, Italy
| | - Carlo Di Bonaventura
- Epilepsy Centre, Department of Human Neurosciences, "Sapienza" University of Rome, Rome, Italy
| | | | | | - Renzo Guerrini
- Neuroscience Department, Children's Hospital A. Meyer-University of Florence, Italy
| | - Angela La Neve
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University Hospital of Bari "A. Moro", Bari, Italy
| | - Oriano Mecarelli
- Department of Human Neurosciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Nicola Pietrafusa
- Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Nicola Specchio
- Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Federico Vigevano
- Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Emilio Perucca
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy, Department of Medicine (Austin Health), University of Melbourne, and Department of Neuroscience, Monash University, Melbourne, Australia
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Charlier B, Coglianese A, Operto FF, Coppola G, de Grazia U, Menna P, Filippelli A, Dal Piaz F, Izzo V. Development and Validation of a UHPLC-MS/MS-Based Method to Quantify Cenobamate in Human Plasma Samples. Molecules 2022; 27:7325. [PMID: 36364153 PMCID: PMC9656984 DOI: 10.3390/molecules27217325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 10/10/2022] [Accepted: 10/18/2022] [Indexed: 08/27/2023] Open
Abstract
Cenobamate (CNB) is the newest antiseizure medication (ASM) approved by the FDA in 2019 to reduce uncontrolled partial-onset seizures in adult patients. Marketed as Xcopri in the USA or Ontozry in the EU (tablets), its mechanism of action has not been fully understood yet; however, it is known that it inhibits voltage-gated sodium channels and positively modulates the aminobutyric acid (GABA) ion channel. CNB shows 88% of oral bioavailability and is responsible for modifying the plasma concentrations of other co-administered ASMs, such as lamotrigine, carbamazepine, phenytoin, phenobarbital and the active metabolite of clobazam. It also interferes with CYP2B6 and CYP3A substrates. Nowadays, few methods are reported in the literature to quantify CNB in human plasma. The aim of this study was to develop and validate, according to the most recent guidelines, an analytical method using ultra-high-performance liquid chromatography coupled with tandem mass spectrometry (UHPLC-MS/MS) to evaluate CNB dosage in plasma samples. Furthermore, we provided a preliminary clinical application of our methodology by evaluating the pharmacokinetic parameters of CNB in two non-adult patients. Plasma levels were monitored for two months. Preliminary data showed a linear increase in plasma CNB concentrations, in both patients, in agreement with the increase in CNB dosage. A seizure-free state was reported for both patients at the dose of 150 mg per day.
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Affiliation(s)
- Bruno Charlier
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Baronissi, 84081 Salerno, Italy
- University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy
| | - Albino Coglianese
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Baronissi, 84081 Salerno, Italy
- Graduate School in Clinical Pathology and Clinical Biochemistry, University of Salerno, Baronissi, 84081 Salerno, Italy
| | - Francesca Felicia Operto
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Baronissi, 84081 Salerno, Italy
- University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy
| | - Giangennaro Coppola
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Baronissi, 84081 Salerno, Italy
- University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy
| | - Ugo de Grazia
- Laboratory of Neurological Biochemistry and Neuropharmacology, Fondazione IRCCS “Istituto Neurologico Carlo Besta”, 20133 Milano, Italy
| | - Pierantonio Menna
- Department of Science and Technology for Humans and the Environment, Università Campus Bio-Medico di Roma, 00128 Roma, Italy
- Operative Research Unit of Clinical Pharmacology, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Roma, Italy
| | - Amelia Filippelli
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Baronissi, 84081 Salerno, Italy
- University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy
| | - Fabrizio Dal Piaz
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Baronissi, 84081 Salerno, Italy
- University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy
| | - Viviana Izzo
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Baronissi, 84081 Salerno, Italy
- University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy
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Aboumatar S, Biton V, Wechsler R, Ferrari L, Rosenfeld WE. Post hoc analysis of a phase 3 study for treatment of uncontrolled focal seizures: Adjunctive cenobamate dose and seizure reduction by baseline seizure frequency. Epilepsy Res 2022; 186:107014. [DOI: 10.1016/j.eplepsyres.2022.107014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 08/18/2022] [Accepted: 08/25/2022] [Indexed: 11/03/2022]
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Elkommos S, Mula M. Current and future pharmacotherapy options for drug-resistant epilepsy. Expert Opin Pharmacother 2022; 23:2023-2034. [PMID: 36154780 DOI: 10.1080/14656566.2022.2128670] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Epilepsy is one of the most common and serious neurological conditions, affecting over 70 million individuals worldwide and despite advances in treatment, the proportion of drug-resistant patients has remained largely unchanged. AREAS COVERED The present paper reviews current and future (under preclinical and clinical development) pharmacotherapy options for the treatment of drug-resistant focal and generalized epilepsies. EXPERT OPINION Current pharmacotherapy options for drug-resistant epilepsy include perampanel, brivaracetam and the newly approved cenobamate for focal epilepsies; cannabidiol (Epidiolex) for Lennox-Gastaut Syndrome (LGS), Dravet and Tuberous Sclerosis Complex (TSC); fenfluramine for Dravet syndrome and ganaxolone for seizures in Cyclin-dependent kinase-like 5 (CDKL5) deficiency disorder. Many compounds are under clinical development and may hold promise for future pharmacotherapies. For adult focal epilepsies, padsevonil and carisbamate are at a more advanced Phase III stage of clinical development followed by compounds at Phase II like selurampanel, XEN1101 and JNJ-40411813. For specific epilepsy syndromes, XEN 496 is under Phase III development for potassium voltage-gated channel subfamily Q member 2 developmental and epileptic encephalopathy (KCNQ2-DEE), carisbamate is under Phase III development for LGS and Ganaxolone under Phase III development for TSC. Finally, in preclinical models several molecular targets including inhibition of glycolysis, neuroinflammation and sodium channel inhibition have been identified in animal models although further data in animal and later human studies are needed.
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Affiliation(s)
- Samia Elkommos
- School of Neuroscience, King's College London, United Kingdom.,Atkinson Morley Regional Neurosciences Centre, St George's University Hospitals, United Kingdom
| | - Marco Mula
- Atkinson Morley Regional Neurosciences Centre, St George's University Hospitals, United Kingdom.,Institute of Medical and Biomedical Education, St George's University London, United Kingdom
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Klein P, Aboumatar S, Brandt C, Dong F, Krauss GL, Mizne S, Sánchez-Álvarez JC, Steinhoff BJ, Villanueva V. Long-term Efficacy and Safety From an Open-Label Extension of Adjunctive Cenobamate in Patients With Uncontrolled Focal Seizures. Neurology 2022; 99:e989-e998. [PMID: 35705501 PMCID: PMC9519254 DOI: 10.1212/wnl.0000000000200792] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 04/11/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To evaluate long-term efficacy (percent seizure frequency reduction and responder rates), safety, and tolerability of adjunctive cenobamate (CNB) in an open-label extension (OLE) of the randomized, double-blind, placebo-controlled study. METHODS Patients (aged 18-70 years) with uncontrolled focal seizures despite treatment with 1-3 antiseizure medications who completed the 18-week double-blind study (n = 360) could enter the OLE, where they underwent a 2-week blinded conversion to CNB (target dose, 300 mg/d; min/max, 50/400 mg/d). RESULTS Three hundred fifty-five patients were included in the OLE safety population (265 originally randomized to CNB, 90 originally randomized to placebo), and 354 were included in the OLE modified intent-to-treat population. As of July 2019, 58.9% of patients (209/355) were continuing CNB treatment and 141 had discontinued, including 16.6% (59/355) because of lack of efficacy, 8.7% (31/355) because of withdrawal by patient, and 7.6% (27/355) because of adverse events. The median (range) duration of OLE exposure was 53.9 (1.1-68.7) months. Retention rates at 12, 24, 36, and 48 months were 83%, 71%, 65%, and 62%, respectively. Median percent seizure frequency reduction over baseline increased with each 6-month OLE interval, up to 76.1% at months 43-48. Among observed patients, 16.4% (36/220) achieved 100% and 39.1% (86/220) achieved ≥90% seizure reduction during >36-48 months. Among the initial OLE modified intent-to-treat population, 10.2% of patients (36/354) achieved 100% and 24.3% (86/354) achieved ≥90% seizure reduction during >36-48 months. Similar to the double-blind study, adverse events (AEs) included dizziness, somnolence, fatigue, and headache. Serious AEs occurred in 20.3% of patients (72/355). DISCUSSION Long-term efficacy, including 100% and ≥90% seizure reduction, was sustained during 48 months of CNB treatment, with 71% retention at 24 months. No new safety issues were identified. These results confirm the findings of the double-blind study and support the potential long-term clinical benefit of CNB. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that oral CNB 50-400 mg/d is effective as an adjunctive treatment for the long-term management of patients with uncontrolled focal seizures previously treated with 1-3 ASMs. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov NCT01866111 (clinicaltrials.gov/ct2/show/results/NCT01866111).
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Affiliation(s)
- Pavel Klein
- From the Mid-Atlantic Epilepsy and Sleep Center (P.K.), Bethesda, MD; Austin Epilepsy Care Center (S.A.), Austin, TX; Bethel Epilepsy Centre (C.B.), Mara Hospital, Bielefeld, Germany; SK Life Science, Inc. (F.D.), Paramus, NJ; Johns Hopkins University School of Medicine (G.L.K.), Baltimore, MD; MedVal Scientific Information Services (S.M.), Princeton, NJ; Unidad de Epilepsia (J.C.S.-A.), Hospital Vithas la Salud, Granada, Spain; Kork Epilepsy Center (B.J.S.), Kehl-Kork, Germany; Department of Neurology and Neurophysiology (B.J.S.), University of Freiburg, Germany; and Refractory Epilepsy Unit (V.V.), Hospital Universitari i Politècnic La Fe, Valencia, Spain.
| | - Sami Aboumatar
- From the Mid-Atlantic Epilepsy and Sleep Center (P.K.), Bethesda, MD; Austin Epilepsy Care Center (S.A.), Austin, TX; Bethel Epilepsy Centre (C.B.), Mara Hospital, Bielefeld, Germany; SK Life Science, Inc. (F.D.), Paramus, NJ; Johns Hopkins University School of Medicine (G.L.K.), Baltimore, MD; MedVal Scientific Information Services (S.M.), Princeton, NJ; Unidad de Epilepsia (J.C.S.-A.), Hospital Vithas la Salud, Granada, Spain; Kork Epilepsy Center (B.J.S.), Kehl-Kork, Germany; Department of Neurology and Neurophysiology (B.J.S.), University of Freiburg, Germany; and Refractory Epilepsy Unit (V.V.), Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Christian Brandt
- From the Mid-Atlantic Epilepsy and Sleep Center (P.K.), Bethesda, MD; Austin Epilepsy Care Center (S.A.), Austin, TX; Bethel Epilepsy Centre (C.B.), Mara Hospital, Bielefeld, Germany; SK Life Science, Inc. (F.D.), Paramus, NJ; Johns Hopkins University School of Medicine (G.L.K.), Baltimore, MD; MedVal Scientific Information Services (S.M.), Princeton, NJ; Unidad de Epilepsia (J.C.S.-A.), Hospital Vithas la Salud, Granada, Spain; Kork Epilepsy Center (B.J.S.), Kehl-Kork, Germany; Department of Neurology and Neurophysiology (B.J.S.), University of Freiburg, Germany; and Refractory Epilepsy Unit (V.V.), Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Fang Dong
- From the Mid-Atlantic Epilepsy and Sleep Center (P.K.), Bethesda, MD; Austin Epilepsy Care Center (S.A.), Austin, TX; Bethel Epilepsy Centre (C.B.), Mara Hospital, Bielefeld, Germany; SK Life Science, Inc. (F.D.), Paramus, NJ; Johns Hopkins University School of Medicine (G.L.K.), Baltimore, MD; MedVal Scientific Information Services (S.M.), Princeton, NJ; Unidad de Epilepsia (J.C.S.-A.), Hospital Vithas la Salud, Granada, Spain; Kork Epilepsy Center (B.J.S.), Kehl-Kork, Germany; Department of Neurology and Neurophysiology (B.J.S.), University of Freiburg, Germany; and Refractory Epilepsy Unit (V.V.), Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Gregory L Krauss
- From the Mid-Atlantic Epilepsy and Sleep Center (P.K.), Bethesda, MD; Austin Epilepsy Care Center (S.A.), Austin, TX; Bethel Epilepsy Centre (C.B.), Mara Hospital, Bielefeld, Germany; SK Life Science, Inc. (F.D.), Paramus, NJ; Johns Hopkins University School of Medicine (G.L.K.), Baltimore, MD; MedVal Scientific Information Services (S.M.), Princeton, NJ; Unidad de Epilepsia (J.C.S.-A.), Hospital Vithas la Salud, Granada, Spain; Kork Epilepsy Center (B.J.S.), Kehl-Kork, Germany; Department of Neurology and Neurophysiology (B.J.S.), University of Freiburg, Germany; and Refractory Epilepsy Unit (V.V.), Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Sarah Mizne
- From the Mid-Atlantic Epilepsy and Sleep Center (P.K.), Bethesda, MD; Austin Epilepsy Care Center (S.A.), Austin, TX; Bethel Epilepsy Centre (C.B.), Mara Hospital, Bielefeld, Germany; SK Life Science, Inc. (F.D.), Paramus, NJ; Johns Hopkins University School of Medicine (G.L.K.), Baltimore, MD; MedVal Scientific Information Services (S.M.), Princeton, NJ; Unidad de Epilepsia (J.C.S.-A.), Hospital Vithas la Salud, Granada, Spain; Kork Epilepsy Center (B.J.S.), Kehl-Kork, Germany; Department of Neurology and Neurophysiology (B.J.S.), University of Freiburg, Germany; and Refractory Epilepsy Unit (V.V.), Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Juan Carlos Sánchez-Álvarez
- From the Mid-Atlantic Epilepsy and Sleep Center (P.K.), Bethesda, MD; Austin Epilepsy Care Center (S.A.), Austin, TX; Bethel Epilepsy Centre (C.B.), Mara Hospital, Bielefeld, Germany; SK Life Science, Inc. (F.D.), Paramus, NJ; Johns Hopkins University School of Medicine (G.L.K.), Baltimore, MD; MedVal Scientific Information Services (S.M.), Princeton, NJ; Unidad de Epilepsia (J.C.S.-A.), Hospital Vithas la Salud, Granada, Spain; Kork Epilepsy Center (B.J.S.), Kehl-Kork, Germany; Department of Neurology and Neurophysiology (B.J.S.), University of Freiburg, Germany; and Refractory Epilepsy Unit (V.V.), Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Bernhard J Steinhoff
- From the Mid-Atlantic Epilepsy and Sleep Center (P.K.), Bethesda, MD; Austin Epilepsy Care Center (S.A.), Austin, TX; Bethel Epilepsy Centre (C.B.), Mara Hospital, Bielefeld, Germany; SK Life Science, Inc. (F.D.), Paramus, NJ; Johns Hopkins University School of Medicine (G.L.K.), Baltimore, MD; MedVal Scientific Information Services (S.M.), Princeton, NJ; Unidad de Epilepsia (J.C.S.-A.), Hospital Vithas la Salud, Granada, Spain; Kork Epilepsy Center (B.J.S.), Kehl-Kork, Germany; Department of Neurology and Neurophysiology (B.J.S.), University of Freiburg, Germany; and Refractory Epilepsy Unit (V.V.), Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Vicente Villanueva
- From the Mid-Atlantic Epilepsy and Sleep Center (P.K.), Bethesda, MD; Austin Epilepsy Care Center (S.A.), Austin, TX; Bethel Epilepsy Centre (C.B.), Mara Hospital, Bielefeld, Germany; SK Life Science, Inc. (F.D.), Paramus, NJ; Johns Hopkins University School of Medicine (G.L.K.), Baltimore, MD; MedVal Scientific Information Services (S.M.), Princeton, NJ; Unidad de Epilepsia (J.C.S.-A.), Hospital Vithas la Salud, Granada, Spain; Kork Epilepsy Center (B.J.S.), Kehl-Kork, Germany; Department of Neurology and Neurophysiology (B.J.S.), University of Freiburg, Germany; and Refractory Epilepsy Unit (V.V.), Hospital Universitari i Politècnic La Fe, Valencia, Spain
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Smith MC, Klein P, Krauss GL, Rashid S, Seiden LG, Stern JM, Rosenfeld WE. Dose Adjustment of Concomitant Antiseizure Medications During Cenobamate Treatment: Expert Opinion Consensus Recommendations. Neurol Ther 2022; 11:1705-1720. [PMID: 36057761 PMCID: PMC9588096 DOI: 10.1007/s40120-022-00400-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/15/2022] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Our objective was to provide expert consensus recommendations to improve treatment tolerability through dose adjustments of concomitant antiseizure medications (ASMs) during addition of cenobamate to existing ASM therapy in adult patients with uncontrolled focal seizures. METHODS A panel of seven epileptologists experienced in the use of ASMs, including cenobamate, used a modified Delphi process to reach consensus. The panelists discussed tolerability issues with concomitant ASMs during cenobamate titration and practical strategies for dose adjustments that may prevent or mitigate adverse effects. The resulting recommendations consider concomitant ASM dose level and specify proactive (prior to report of an adverse effect) and reactive (in response to report of an adverse effect) dose adjustment suggestions based on concomitant ASM pharmacokinetic and pharmacodynamic interactions with cenobamate. Specific dose adjustment recommendations are provided. RESULTS We recommend proactively lowering the dose of clobazam, phenytoin, and phenobarbital due to their known drug-drug interactions with cenobamate, and lacosamide due to a pharmacodynamic interaction with cenobamate, to prevent adverse effects during cenobamate titration. Reactive lowering of a concomitant ASM dose is sufficient for other ASMs at standard dosing owing to quick resolution of adverse effects. For carbamazepine and lamotrigine doses exceeding the upper end of standard dosing (e.g., carbamazepine, greater than 1200 mg/day; lamotrigine, greater than 500 mg/day), we encourage consideration of proactive dose reduction at cenobamate 200 mg/day to prevent potential adverse effects. All dose reductions for adverse effects can be repeated every 2 weeks as dictated by the adverse effects. At cenobamate 200 mg/day, we recommend that patients be evaluated for marked improvement of seizures and further dose reductions be considered to reduce potentially unnecessary polypharmacy. CONCLUSION The primary goal of the recommended dose reductions of concomitant ASMs is to prevent or resolve adverse effects, thereby allowing cenobamate to reach the optimal dose to achieve the maximal potential of improving seizure control.
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Affiliation(s)
- Michael C. Smith
- Department of Neurological Sciences, Section of Clinical Neurophysiology and Epilepsy, Rush Medical College, 1725 W. Harrison Street, Suite 885, Chicago, IL 60612 USA
| | - Pavel Klein
- Mid-Atlantic Epilepsy and Sleep Center, Bethesda, MD USA
| | | | - Samiya Rashid
- Epilepsy and Neurology Specialists of San Diego, Encinitas, CA USA
| | | | - John M. Stern
- University of California at Los Angeles, Los Angeles, CA USA
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Sáenz-Farret M, Tijssen MAJ, Eliashiv D, Fisher RS, Sethi K, Fasano A. Antiseizure Drugs and Movement Disorders. CNS Drugs 2022; 36:859-876. [PMID: 35861924 DOI: 10.1007/s40263-022-00937-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2022] [Indexed: 11/03/2022]
Abstract
The relationship between antiseizure drugs and movement disorders is complex and not adequately reviewed so far. Antiseizure drugs as a treatment for tremor and other entities such as myoclonus and restless leg syndrome is the most common scenario, although the scientific evidence supporting their use is variable. However, antiseizure drugs also represent a potential cause of iatrogenic movement disorders, with parkinsonism and tremor the most common disorders. Many other antiseizure drug-induced movement disorders are possible and not always correctly identified. This review was conducted by searching for all the possible combinations between 15 movement disorders (excluding ataxia) and 24 antiseizure drugs. The main objective was to describe the movement disorders treated and worsened or induced by antiseizure drugs. We also summarized the proposed mechanisms and risk factors involved in the complex interaction between antiseizure drugs and movement disorders. Antiseizure drugs mainly used to treat movement disorders are clonazepam, gabapentin, lacosamide, levetiracetam, oxcarbazepine, perampanel, phenobarbital, pregabalin, primidone, topiramate, and zonisamide. Antiseizure drugs that worsen or induce movement disorders are cenobamate, ethosuximide, felbamate, lamotrigine, phenytoin, tiagabine, and vigabatrin. Antiseizure drugs with a variable effect on movement disorders are carbamazepine and valproate while no effect on movement disorders has been reported for brivaracetam, eslicarbazepine, lacosamide, and stiripentol. Although little information is available on the adverse effects or benefits on movement disorders of newer antiseizure drugs (such as brivaracetam, cenobamate, eslicarbazepine, lacosamide, and rufinamide), the evidence collected in this review should guide the choice of antiseizure drugs in patients with concomitant epilepsy and movement disorders. Finally, these notions can lead to a better understanding of the mechanisms involved in the pathophysiology and treatments of movement disorders.
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Affiliation(s)
- Michel Sáenz-Farret
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, Division of Neurology, University of Toronto, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada
| | - Marina A J Tijssen
- Department of Neurology, University of Groningen, Groningen, The Netherlands.,Expertise Center Movement Disorders Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Dawn Eliashiv
- UCLA Seizure Disorder Center, Department of Neurology, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Robert S Fisher
- Departments of Neurology and Neurological Sciences and Neurosurgery, Stanford University, Stanford, CA, USA
| | - Kapil Sethi
- Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, Division of Neurology, University of Toronto, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada. .,Krembil Brain Institute, Toronto, ON, Canada. .,Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, ON, Canada.
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Efficacy of cenobamate for uncontrolled focal seizures in patients with previous epilepsy-related surgery: Post hoc analysis of a phase 3, multicenter, open-label study. Epilepsy Res 2022; 184:106952. [DOI: 10.1016/j.eplepsyres.2022.106952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/06/2022] [Accepted: 05/25/2022] [Indexed: 11/23/2022]
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Ángel Calleja M, Navarro A, Serratosa JM, Toledo M, Villanueva V, Subías Labazuy S, Gil A. Determination of the economically justifiable price of cenobamate in the treatment of focal-onset seizures in adult patients with drug-resistant epilepsy in Spain. Expert Rev Pharmacoecon Outcomes Res 2022; 22:1127-1136. [PMID: 35904256 DOI: 10.1080/14737167.2022.2107507] [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
OBJECTIVE To determine the economically justifiable price (EJP) of cenobamate to become a cost-effective alternative compared with third-generation anti-seizure medications in the treatment of focal-onset seizures (FOS) in adult patients with drug-resistant epilepsy (DRE) in Spain. METHODS Cost-effectiveness analysis comparing cenobamate with brivaracetam, perampanel, eslicarbazepine acetate and lacosamide. Markov model simulation of treatment pathway over a 60-year time horizon. Determination of effectiveness and quality-adjusted life-years (QALYs) of each health status, and disutilities associated with treatment-related adverse events. Acquisition costs and use of medical resources were obtained from published literature and expert opinion. Base-case of cenobamate's EJP calculated applying a willingness-to-pay (WTP) threshold of €21,000/QALY. Analyses performed at different thresholds, including dominant price scenario. Results robustness were assessed through sensitivity analyses. RESULTS Base-case shows that cenobamate's daily EJP of €7.30 is cost-effective for a threshold of €21,000/QALY. At a daily price of €5.45, cenobamate becomes dominant over all treatment alternatives producing cost-savings for the national health system (NHS). Sensitivity analyses supported the robustness of base-case findings. CONCLUSIONS Treatment with cenobamate produces incremental clinical benefit over third generation ASMs and at the base-case EJP could represent a cost-effective option for the adjunctive treatment of FOS in adult patients with DRE in Spain.
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Makridis KL, Bast T, Prager C, Kovacevic-Preradovic T, Bittigau P, Mayer T, Breuer E, Kaindl AM. Real-World Experience Treating Pediatric Epilepsy Patients With Cenobamate. Front Neurol 2022; 13:950171. [PMID: 35937072 PMCID: PMC9350548 DOI: 10.3389/fneur.2022.950171] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 06/23/2022] [Indexed: 12/02/2022] Open
Abstract
Introduction In one third of all patients with epilepsy, seizure freedom is not achieved through anti-seizure medication (ASM). These patients have an increased risk of earlier death, poorer cognitive development, and reduced quality of life. Cenobamate (CNB) has recently been approved as a promising novel ASM drug for the treatment of adults with focal-onset epilepsy. However, there is little experience for its application in pediatric patients. Methods In a multicenter study we evaluated retrospectively the outcome of 16 pediatric patients treated “off label” with CNB. Results In 16 patients with a mean age of 15.38 years, CNB was started at an age of 15.05 years due to DRE. Prior to initiation of therapy, an average of 10.56 (range 3–20) ASM were prescribed. At initiation, patients were taking 2.63 (range 1–4) ASM. CNB was increased by 0.47 ± 0.27mg/kg/d every 2 weeks with a mean maximum dosage of 3.1 mg/kg/d (range 0.89–7) and total daily dose of 182.81 mg (range 50–400 mg). Seizure freedom was achieved in 31.3% and a significant seizure reduction of >50% in 37.5%. Adverse events occurred in 10 patients with fatigue/somnolence as the most common. CNB is taken with high adherence in all but three patients with a median follow-up of 168.5 days Conclusion Cenobamate is an effective ASM for pediatric patients suffering from drug-resistant epilepsy. In addition to excellent seizure reduction or freedom, it is well-tolerated. Cenobamate should be considered as a novel treatment for DRE in pediatric patients.
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Affiliation(s)
- Konstantin L. Makridis
- Department of Pediatric Neurology, Charité–Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité–Universitätsmedizin Berlin, Berlin, Germany
- German Epilepsy Center for Children and Adolescents, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Institute of Cell- and Neurobiology, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Bast
- Epilepsiezentrum Kork, Diakonie Kork, Kehl, Germany
| | - Christine Prager
- Department of Pediatric Neurology, Charité–Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité–Universitätsmedizin Berlin, Berlin, Germany
- German Epilepsy Center for Children and Adolescents, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Petra Bittigau
- Department of Pediatric Neurology, Charité–Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité–Universitätsmedizin Berlin, Berlin, Germany
- German Epilepsy Center for Children and Adolescents, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Mayer
- Epilepsiezentrum Kleinwachau gemeinnützige GmbH, Radeberg, Germany
| | - Eva Breuer
- Epilepsie-Zentrum Berlin-Brandenburg, Ev. Krankenhaus Königin Elisabeth Herzberge, Berlin, Germany
| | - Angela M. Kaindl
- Department of Pediatric Neurology, Charité–Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité–Universitätsmedizin Berlin, Berlin, Germany
- German Epilepsy Center for Children and Adolescents, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Institute of Cell- and Neurobiology, Charité–Universitätsmedizin Berlin, Berlin, Germany
- *Correspondence: Angela M. Kaindl
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