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Gronich N. Central Nervous System Medications: Pharmacokinetic and Pharmacodynamic Considerations for Older Adults. Drugs Aging 2024:10.1007/s40266-024-01117-w. [PMID: 38814377 DOI: 10.1007/s40266-024-01117-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2024] [Indexed: 05/31/2024]
Abstract
Most drugs have not been evaluated in the older population. Recognizing physiological alterations associated with changes in drug disposition and with the ultimate effect, especially in central nervous system-acting drugs, is fundamental. While considering pharmacokinetics, it should be noted that the absorption of most drugs from the gastrointestinal tract does not change in advanced age. There are only few data about the effect of age on the transdermal absorption of medications such as fentanyl. Absorption from an intramuscular injection may be similar in older adults as in younger patients. The distribution of lipophilic drugs (such as diazepam) is increased owing to a relative increase in the percentage of body fat, causing drug accumulation and prolonged drug elimination following cessation. Phase I drug biotransformation is variably decreased in aging, impacting elimination, and hepatic drug clearance has been shown to decrease in older individuals by 10-40% for most drugs studied. Lower doses of phenothiazines, butyrophenones, atypical antipsychotics, antidepressants (citalopram, mirtazapine, and tricyclic antidepressants), and benzodiazepines (such as diazepam) achieve the same extent of exposure. For renally cleared drugs with no prior metabolism (such as gabapentin), the glomerular filtration rate appropriately estimates drug clearance. Important pharmacodynamic changes in older adults include an increased sedative effect of benzodiazepines at a given drug exposure, and a higher sensitivity to mu opiate receptor agonists and to opioid adverse effects. Artificial intelligence, physiologically based pharmacokinetic modeling and simulation, and concentration-effect modeling enabling a differentiation between the pharmacokinetic and the pharmacodynamic effects of aging might help to close some of the gaps in knowledge.
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Affiliation(s)
- Naomi Gronich
- Department of Community Medicine and Epidemiology, Lady Davis Carmel Medical Center, Clalit Health Services, 7 Michal St, 3436212, Haifa, Israel.
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, 3200003, Haifa, Israel.
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2
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Gilmour GS, Salmon A, Josephson CB. Functional Seizures in the Elderly: Accurate Diagnosis Can Reduce Iatrogenic Harm. Can J Neurol Sci 2024; 51:330-332. [PMID: 36600669 DOI: 10.1017/cjn.2022.349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Gabriela S Gilmour
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrea Salmon
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Colin B Josephson
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences and O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- Centre for Health Informatics, University of Calgary, Calgary, Alberta, Canada
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3
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Palamanda J, Glenn KJ, Melnick SM. Distribution, Metabolism, and Excretion of Cenobamate in Adult, Fetal, Neonatal, and Lactating Rats. Eur J Drug Metab Pharmacokinet 2024; 49:7-21. [PMID: 37921950 DOI: 10.1007/s13318-023-00862-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2023] [Indexed: 11/05/2023]
Abstract
BACKGROUND AND OBJECTIVE Cenobamate is an antiseizure medication (ASM) approved for treatment of focal epilepsy in adults. The objective of this study was to characterize the distribution, metabolism, and excretion of cenobamate in adult and pre- and postnatal rats, including pregnant and lactating females and nursing pups. METHODS Distribution, metabolic, and excretion profiles were determined for 14C-labeled and unlabeled cenobamate using liquid scintillation counting, radiochromatography, LCMS, and LCMS/MS after oral or intravenous (IV) administration. RESULTS Distribution of 14C-cenobamate-related material in adult male rats was widespread throughout the body, with nearly 1:1 tissue-to-plasma ratios observed for most tissues, including brain. Cenobamate administered to pregnant females was also transferred across the placental barrier into amniotic fluid and fetal plasma. Following administration to lactating F0 females, cenobamate was detected in breast milk and in plasma of nursing pups. 14C-cenobamate administered to adult male rats as a single oral dose was extensively metabolized with nine metabolites identified in urine and feces, including a principal dihydrodiol metabolite. Cenobamate was the principal drug-related material in rat plasma. Following a single dose of 14C-cenobamate to male and female rats, radioactivity was excreted equally into urine and feces, with mass balance achieved by 48 h postdose. CONCLUSIONS Distribution of cenobamate was widespread into many rat tissues, including brain, amniotic fluid, fetal plasma, breast milk, and breastfeeding rat pups. These distribution findings, along with the results of the metabolism and excretion studies, may help inform treatment decisions for patients with epilepsy being treated with cenobamate, including pregnant or nursing mothers.
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Affiliation(s)
- Jairam Palamanda
- Nonclinical, SK Life Science, Inc., 461 From Road, 5th Floor, Paramus, NJ, 07652, USA.
| | - Kelli J Glenn
- Nonclinical, SK Life Science, Inc., 461 From Road, 5th Floor, Paramus, NJ, 07652, USA
| | - Susan M Melnick
- Nonclinical, SK Life Science, Inc., 461 From Road, 5th Floor, Paramus, NJ, 07652, USA
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Josephson CB, Gonzalez-Izquierdo A, Engbers JDT, Denaxas S, Delgado-Garcia G, Sajobi TT, Wang M, Keezer MR, Wiebe S. Association of comorbid-socioeconomic clusters with mortality in late onset epilepsy derived through unsupervised machine learning. Seizure 2023; 111:58-67. [PMID: 37536152 DOI: 10.1016/j.seizure.2023.07.016] [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: 05/05/2023] [Revised: 07/20/2023] [Accepted: 07/22/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Late-onset epilepsy is a heterogenous entity associated with specific aetiologies and an elevated risk of premature mortality. Specific multimorbid-socioeconomic profiles and their unique prognostic trajectories have not been described. We sought to determine if specific clusters of late onset epilepsy exist, and whether they have unique hazards of premature mortality. METHODS We performed a retrospective observational cohort study linking primary and hospital-based UK electronic health records with vital statistics data (covering years 1998-2019) to identify all cases of incident late onset epilepsy (from people aged ≥65) and 1:10 age, sex, and GP practice-matched controls. We applied hierarchical agglomerative clustering using common aetiologies identified at baseline to define multimorbid-socioeconomic profiles, compare hazards of early mortality, and tabulating causes of death stratified by cluster. RESULTS From 1,032,129 people aged ≥65, we identified 1048 cases of late onset epilepsy who were matched to 10,259 controls. Median age at epilepsy diagnosis was 68 (interquartile range: 66-72) and 474 (45%) were female. The hazard of premature mortality related to late-onset epilepsy was higher than matched controls (hazard ratio [HR] 1.73; 95% confidence interval [95%CI] 1.51-1.99). Ten unique phenotypic clusters were identified, defined by 'healthy' males and females, ischaemic stroke, intracerebral haemorrhage (ICH), ICH and alcohol misuse, dementia and anxiety, anxiety, depression in males and females, and brain tumours. Cluster-specific hazards were often similar to that derived for late-onset epilepsy as a whole. Clusters that differed significantly from the base late-onset epilepsy hazard were 'dementia and anxiety' (HR 5.36; 95%CI 3.31-8.68), 'brain tumour' (HR 4.97; 95%CI 2.89-8.56), 'ICH and alcohol misuse' (HR 2.91; 95%CI 1.76-4.81), and 'ischaemic stroke' (HR 2.83; 95%CI 1.83-4.04). These cluster-specific risks were also elevated compared to those derived for tumours, dementia, ischaemic stroke, and ICH in the whole population. Seizure-related cause of death was uncommon and restricted to the ICH, ICH and alcohol misuse, and healthy female clusters. SIGNIFICANCE Late-onset epilepsy is an amalgam of unique phenotypic clusters that can be quantitatively defined. Late-onset epilepsy and cluster-specific comorbid profiles have complex effects on premature mortality above and beyond the base rates attributed to epilepsy and cluster-defining comorbidities alone.
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Affiliation(s)
- Colin B Josephson
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, AB, Canada; Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada; Centre for Health Informatics, University of Calgary, Calgary, AB, Canada
| | | | | | - Spiros Denaxas
- UCL Institute of Health Informatics, London, UK; Health Data Research (HDR) UK, London, UK; Alan Turing Institute, London, UK
| | - Guillermo Delgado-Garcia
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Tolulope T Sajobi
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, AB, Canada; Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Meng Wang
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Mark R Keezer
- Department of Neurosciences, Université de Montreal, Montreal, Quebec, Canada
| | - Samuel Wiebe
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, AB, Canada; Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada; Clinical Research Unit, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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5
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Oh H, Im K, Yang HR, Kim HJ, Koo YS, Lee SA. Seizure outcome in medically treated patients with adult-onset epilepsy and cerebral cavernous malformation. Clin Neurol Neurosurg 2023; 233:107951. [PMID: 37683297 DOI: 10.1016/j.clineuro.2023.107951] [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: 06/07/2023] [Revised: 08/02/2023] [Accepted: 08/24/2023] [Indexed: 09/10/2023]
Abstract
PURPOSE We evaluated long-term seizure outcomes of antiseizure medications (ASMs) and risk factors for drug resistance in patients with adult-onset epilepsy associated with cerebral cavernous malformation (CCM). MATERIALS AND METHODS This retrospective observational study included patients newly diagnosed with adult-onset focal epilepsy associated with CCM. Patients received individualized treatments with ASMs. All patients were followed-up for at least 2 years. The main outcome measure was terminal 2 year seizure freedom (2-YSF). RESULTS Forty eight subjects (28 men and 20 women) were included. Thirty-one (64.6%) subjects achieved a terminal 2-YSF (range 2.0-17.0 years). After treatment with the first drug regimen, 31 (64.6%) subjects achieved 2-YSF, with 23 remaining seizure-free until final follow-up visit. Of the 23 subjects treated with the second drug regimen and the six treated with the third drug regimen, ten (43.5%) and one (16.7%), respectively, achieved a terminal 2-YSF. Stepwise logistic regression analyses showed that terminal 2-YSF was negatively associated with epileptiform discharge on EEG at the time of diagnosis (odds ratio = 0.214, p = 0.047) and tended to be associated with age ≥ 45 years at seizure onset (odds ratio = 4.260, p = 0.056). CONCLUSION The present study found that 64.6% of CCM patients with adult-onset epilepsy achieved terminal 2-YSF after ASM initiation. Interictal epileptiform discharge on EEG at the time of diagnosis was associated with poor prognosis. Failure to achieve sustained seizure freedom after two ASMs may indicate the need for surgical treatment.
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Affiliation(s)
- Hyunsun Oh
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kayeong Im
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ha-Rin Yang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyo Jae Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yong Seo Koo
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Ahm Lee
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Perucca E, Perucca P, White HS, Wirrell EC. Drug resistance in epilepsy. Lancet Neurol 2023:S1474-4422(23)00151-5. [PMID: 37352888 DOI: 10.1016/s1474-4422(23)00151-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/23/2023] [Accepted: 04/06/2023] [Indexed: 06/25/2023]
Abstract
Drug resistance is estimated to affect about a third of individuals with epilepsy, but its prevalence differs in relation to the epilepsy syndrome, the cause of epilepsy, and other factors such as age of seizure onset and presence of associated neurological deficits. Although drug-resistant epilepsy is not synonymous with unresponsiveness to any drug treatment, the probability of achieving seizure freedom on a newly tried medication decreases with increasing number of previously failed treatments. After two appropriately used antiseizure medications have failed to control seizures, individuals should be referred whenever possible to a comprehensive epilepsy centre for diagnostic re-evaluation and targeted management. The feasibility of epilepsy surgery and other treatments, including those targeting the cause of epilepsy, should be considered early after diagnosis. Substantial evidence indicates that a delay in identifying an effective treatment can adversely affect ultimate outcome and carry an increased risk of cognitive disability, other comorbidities, and premature mortality. Research on mechanisms of drug resistance and novel therapeutics is progressing rapidly, and potentially improved treatments, including those targeting disease modification, are on the horizon.
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Affiliation(s)
- Emilio Perucca
- Department of Medicine, Austin Health, University of Melbourne, Melbourne, VIC, Australia; Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia.
| | - Piero Perucca
- Department of Medicine, Austin Health, University of Melbourne, Melbourne, VIC, Australia; Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia; Bladin-Berkovic Comprehensive Epilepsy Program, Department of Neurology, Austin Health, Melbourne, VIC, Australia; Department of Neurology, Royal Melbourne Hospital, Melbourne, VIC, Australia; Department of Neurology, Alfred Health, Melbourne, VIC, Australia
| | - H Steve White
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Elaine C Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN, USA
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7
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Jang Y, Lee HS, Kim MS, Lee J, Jung KY. Anti-seizure medication prescription in epilepsy patients in South Korea: A seven-year population-based retrospective cohort study. Seizure 2023; 109:70-76. [PMID: 37267669 DOI: 10.1016/j.seizure.2023.05.013] [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: 01/28/2023] [Revised: 04/29/2023] [Accepted: 05/15/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND AND OBJECTIVES This study aimed to explore the natural history of patients with epilepsy using overall antiseizure-medication (ASM) treatment patterns on a nationwide scale in South Korea. METHODS We investigated a retrospective longitudinal cohort of patients with epilepsy in South Korea using nationwide data from the Korean National Health Information Database of the Health Insurance and Review Assessment Service between January 1st, 2009, and December 31st, 2018. Histories of each patient's ASM prescription were followed for up to 7 years from the index date, the first observed date of ICD-10 epilepsy diagnosis codes with at least one ASM prescription. RESULTS Of 82,390 incident patients analyzed, ten thousand and fifty-nine were followed up to seven years, and nearly 60% of them discontinued the ASM(s). The proportion of patients with possible drug-resistant epilepsy (DRE), who experience three or more types of ASMs, gradually increased, reaching approximately 8.8% of the total number of patients in the seventh year (6.45% for adults, 21.8% for children). The duration of progression for half of the patients with possible DRE was 1.29 years for children, 1.79 years for adults, and 1.62 years for mixed-age patients. However, even in the sixth year, 72 cases progressed to possible DRE, and 6 cases with possible DRE discontinued ASMs in the next year, showing a dynamic process. DISCUSSION Our population-based study showed the dynamic changes of anti-seizure medication prescription in epilepsy patients with real-world data, which slowly stabilizes over years after the first diagnosis of epilepsy.
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Affiliation(s)
- Yoonhyuk Jang
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Han Sang Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Min Sun Kim
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea.
| | - Ki-Young Jung
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea; Seoul National University Hospital Sensory Organ Research Institute, Seoul, Republic of Korea; Seoul National University Medical Research Center Neuroscience Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea.
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8
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O'Dwyer R, Foster E, Leppik I, Kwan P. Pharmacological treatment for older adults with epilepsy and comorbid neurodegenerative disorders. Curr Opin Neurol 2023; 36:117-123. [PMID: 36762636 DOI: 10.1097/wco.0000000000001143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
PURPOSE OF REVIEW An increased interest in epilepsy in older adults has emerged as the global population ages. The purpose of this article is to review the literature regarding the pharmacological treatment of epilepsy in older adults, highlighting issues specifically pertinent to those living with comorbid neurodegenerative disorders. RECENT FINDINGS Although new original research remains sparse, in the last 5 years, there has been a growing number of studies addressing the relationship between epilepsy and neurodegenerative disorders. Accurate diagnosis is incredibly challenging with electroencephalogram findings often requiring circumspect interpretation. Older individuals are often excluded from or under-represented in clinical trials, and there are sparse guidelines offered on the management of these patients, with even less available in reference to those with neurodegenerative comorbidities. SUMMARY We propose that seizures occurring earlier in the neurodegenerative process should be treated aggressively, with the goal to inhibit neuro-excitotoxicity and the associated neuronal loss. By strategically choosing newer antiseizure medications with less adverse effects and a holistic approach to treatment, a patient's time living independently can be conserved. In addition, we advocate for original, multinational collaborative research efforts.
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Affiliation(s)
- Rebecca O'Dwyer
- Rush Epilepsy Center, Rush University Medical Center, Chicago, Illinois, USA
| | - Emma Foster
- Central Clinical School, Monash University
- Neurology Department, The Alfred, Melbourne, Victoria, Australia
| | - Ilo Leppik
- MINCEP Epilepsy Care, University of Minnesota, Minneapolis, Minnesota, USA
| | - Patrick Kwan
- Central Clinical School, Monash University
- Neurology Department, The Alfred, Melbourne, Victoria, Australia
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9
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Nagarajan E, Lynch TM, Frawley B, Bunch ME. Tolerability of clobazam as add-on therapy in patients aged 50 years and older with drug-resistant epilepsy. Neurol Sci 2023:10.1007/s10072-023-06765-1. [PMID: 36964317 DOI: 10.1007/s10072-023-06765-1] [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: 12/23/2022] [Accepted: 03/16/2023] [Indexed: 03/26/2023]
Abstract
OBJECTIVE To evaluate the tolerability of clobazam in patients with drug-resistant epilepsy aged 50 years and older. METHODS We performed a single center, retrospective chart review of patients at least 50 years of age with drug resistant epilepsy of any type who started clobazam as an add on therapy. Retention rate, safety, and tolerability at 6 and 12 months and last follow-up, and the discontinuation rate due to side effects were analyzed. RESULTS A total of 26 patients met inclusion criteria. Mean age was 62 ± 7.1 years, and 69.2% of patients were female. The mean baseline seizure frequency before initiation of clobazam was 2 (range 1-30) seizures per month. The mean total daily dose of clobazam administered was 13 (range 5 to 30) mg/day. At the 12-month follow-up visit after clobazam initiation, 40% of patients were seizure-free and an additional 45% of patients had > 50% reduction in seizure frequency. The mean seizure frequency at 12-month follow-up was 1.5 (range 0-24) seizures per month. The mean total dose of clobazam at 12-month follow-up was 14.25 (range 5 to 25) mg/day. The mean duration of clobazam at last follow was 55.2 ± 27.02 (mean ± SD months) and 18 (69.2%) patients remained on clobazam. Twenty out of 26 (76.9%) patients reported at least one side effect and 6/26 (23%) discontinued the medication within a month of initiation. At last follow-up, 40% remained seizure free on stable dosing. CONCLUSION Clobazam can be a safe and tolerable, add-on treatment older adults with drug-resistant epilepsy. Those who responded tolerated the medication well. Discontinuation due to side effects occurred soon after initiation of therapy.
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Affiliation(s)
- Elanagan Nagarajan
- Department of Neurology, Division of Epilepsy, Albany Medical College, Albany, NY, 12208, USA.
- Department of Neurology, Erlanger Health System, Chattanooga, TN, 47308, USA.
| | - Timothy M Lynch
- Department of Neurology, Division of Epilepsy, Albany Medical College, Albany, NY, 12208, USA
| | - Bridget Frawley
- Department of Neurology, Division of Epilepsy, Albany Medical College, Albany, NY, 12208, USA
| | - Marjorie E Bunch
- Department of Neurology, Division of Epilepsy, Albany Medical College, Albany, NY, 12208, USA
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Birnbaum A. Progress Toward Obtaining Seizure Freedom With New Medications in Older Adults. Epilepsy Curr 2021; 21:267-269. [PMID: 34690564 PMCID: PMC8512911 DOI: 10.1177/15357597211015659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Characteristics and Treatment Outcomes of Newly Diagnosed Epilepsy in Older
People: A 30-Year Longitudinal Cohort Study Alsfouk BAA, Hakeem H, Chen Z, Walters M, Brodie MJ, Kwan P.
Epilepsia. 2020;61(12):2720-2728. doi:10.1111/epi.16721 Objectives: To describe the clinical characteristics and evaluate the long-term treatment
outcomes in older people with newly diagnosed epilepsy over the past 30 years.
Methods: We included patients newly diagnosed with epilepsy and commenced on
anti-seizure medications (ASMs) at age 65 years or older between July 1982 and
October 2012 at the Western infirmary in Glasgow, Scotland. They were followed up
until April 2016 or death. Seizure freedom was defined as no seizure for at least 1
year on unchanged medication at the last follow-up. Results: A total of 201 patients
(median age 73 years, 59% male) were included. The median duration from initial
seizure to starting treatment was 8 months (interquartile range: 3.0-24.0 months);
42.2% (85/201) patients had more than 5 seizures before commencing treatment. Brain
imaging showed potentially epileptogenic lesions in 19.7% (38/193) of patients and
other abnormalities in 56.5% (109/193); 78.6% patients (158/201) were seizure-free
at the last follow-up, of whom 94.9% were taking monotherapy. Concomitant aspirin
use (n = 80) was associated with a lower probability of being seizure-free (relative
risk 0.82, 95% confidence interval 0.70-0.97; P = .02). The use of
second-generation ASMs as the initial monotherapy increased from 31.5% (23/73)
before 2000 to 70.3% (90/128, P < .001) from 2000 onward.
However, the seizure freedom rates (67.1% vs 55.5%; P = .35) and
intolerable adverse-effect rates (16.4% vs 19.5%; P = .45) did not
show any significant difference. Significance: There was often a long interval
between seizure onset and the initiation of treatment in older people with new-onset
epilepsy, although the majority responded well to ASM treatment. Brain imaging
showed a high rate of abnormalities. Despite the increased use of second-generation
ASMs, treatment outcomes in later-onset epilepsy have not improved over time. The
possible effect of aspirin on treatment response warrants further investigation.
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11
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Simpson HD, Foster E, Ademi Z, Lawn N, Brodie MJ, Chen Z, Kwan P. Markov modelling of treatment response in a 30-year cohort study of newly diagnosed epilepsy. Brain 2021; 145:1326-1337. [PMID: 34694369 DOI: 10.1093/brain/awab401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 09/02/2021] [Accepted: 10/01/2021] [Indexed: 11/13/2022] Open
Abstract
People with epilepsy have variable and dynamic trajectories in response to antiseizure medications. Accurately modelling long-term treatment response will aid prognostication at the individual level and health resource planning at the societal level. Unfortunately, a robust model is lacking. We aimed to develop a Markov model to predict the probability of future seizure-freedom based on current seizure state and number of antiseizure medication regimens trialled. We included 1,795 people with newly diagnosed epilepsy who attended a specialist clinic in Glasgow, Scotland, between July 1982 and October 2012. They were followed up until October 2014 or death. We developed a simple Markov model, based on current seizure state only, and a more detailed model, based on both current seizure state and number of antiseizure medication regimens trialled. Sensitivity analyses were performed for the regimen-based states model to examine the effect of regimen changes due to adverse effects. The model was externally validated in a separate cohort of 455 newly diagnosis epilepsy patients seen in Perth, Australia, between May 1999 and May 2016. Our models suggested that once seizure-freedom was achieved, it was likely to persist, regardless of the number of antiseizure medications trialled to reach that point. The likelihood of achieving long-term seizure-freedom was highest with the first antiseizure medication regimen, at approximately 50%. The chance of achieving seizure-freedom fell with subsequent regimens. Fluctuations between seizure-free and not seizure-free states were highest earlier on, but decreased with chronicity of epilepsy. Seizure-freedom/recurrence risk tables were constructed with these probability data, similar to cardiovascular risk tables. Sensitivity analyses showed that the general trends and conclusions from the base model were maintained despite perturbing the model and input data with regimen changes due to adverse effects. Quantitative comparison with the external validation cohort showed excellent consistency at year 1, good at year 3 and moderate at year 5. Quantitative models, as used in this study, can provide pertinent clinical insights that are not apparent from simple statistical analysis alone. Attaining seizure freedom at any time in a patient's epilepsy journey will confer durable benefit. Seizure-freedom risk tables may be used to individualise the prediction of future seizure control trajectory.
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Affiliation(s)
- Hugh D Simpson
- Department of Neurology, Alfred Hospital, Melbourne VIC 3004, Australia
| | - Emma Foster
- Department of Neurology, Alfred Hospital, Melbourne VIC 3004, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne VIC 3800, Australia
| | - Zanfina Ademi
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne VIC 3800, Australia.,School of Public Health & Preventative Medicine, Monash University, Melbourne VIC 3800, Australia
| | - Nicholas Lawn
- Western Australia Adult Epilepsy Service, Sir Charles Gairdner Hospital, Perth WA 6009, Australia
| | | | - Zhibin Chen
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne VIC 3800, Australia.,School of Public Health & Preventative Medicine, Monash University, Melbourne VIC 3800, Australia.,Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville VIC 3050, Australia
| | - Patrick Kwan
- Department of Neurology, Alfred Hospital, Melbourne VIC 3004, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne VIC 3800, Australia.,School of Public Health & Preventative Medicine, Monash University, Melbourne VIC 3800, Australia.,Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville VIC 3050, Australia
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12
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Brigo F, Lattanzi S. Pharmacotherapeutic considerations for late-onset epilepsy. Expert Opin Pharmacother 2020; 22:389-391. [PMID: 33377404 DOI: 10.1080/14656566.2020.1865311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Francesco Brigo
- Department of Neurology, Franz Tappeiner Hospital, Merano, Italy
| | - Simona Lattanzi
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Ancona, Italy
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