Determinants of health-related quality of life in pharmacoresistant epilepsy: results from a large multicenter study of consecutively enrolled patients using validated quantitative assessments

Health priorities and treatment preferences of adults with epilepsy: A narrative literature review with a systematic search

The care of people with epilepsy can be complex. Seizure control is a top priority, however there are other important health-related factors that can impact the well-being of a person with epilepsy. Understanding the range of health priorities and treatment preferences is a critical step in facilitating patient-centered care. In this narrative review, we queried four electronic databases with search terms including patient preferences, needs, priorities, and goals. In total, 20 articles met criteria to be included in the review; these included both quantitative and qualitative analyses of patient responses. Key issues identified were a variety of seizure-specific priorities (such as frequency, duration, severity, warning) and non-seizure medical priorities (such as cognition, mood, physical side effects). Support needs (such as psychological support, improved access to health care) and life goals (such as driving, relationships, work) were also prevalent and emphasized. The range of these findings support the importance of querying individual priorities to promote patient-centered care. Additionally, our results demonstrate that non-medical considerations are an important piece of the illness of epilepsy and should be considered in health care encounters as possible to improve patient outcomes and overall well-being.

Altered neural avalanche spreading in people with drug-resistant epilepsy✰

OBJECTIVE

To characterize a peculiar "EEG endophenotype" of drug-resistant epilepsy (DRE) through the graph theory characterization of avalanche spatiotemporal spreading properties.

METHODS

We performed avalanche analysis and computed avalanche transition matrices (ATMs) on 19-channel scalp EEG of 120 people with epilepsy (60 DRE and 60 non-DRE) who assumed two anti-seizure medications, comparing such results with a group of 40 healthy subjects (HS). Network topologies of ATMs were characterized through graph theory metrics. We performed an analysis of variance to compare aperiodic metrics between HS, DRE and non-DRE. Logistic regression was performed to test and compare the ability of graph theory metrics on ATM and clinical features to correctly discriminate the PwE group according to the clinical outcome (DRE or non-DRE).

RESULTS

DRE exhibited a peculiar altered avalanche spreading as proved by the higher mean betweenness centrality, the longer characteristic path length and the lower small-world index (more regular and less plastic network topology) of ATMs than non-DRE and HS (p-values from <0.001 to 0.05). Graph metrics on ATMs significantly improved the yield of detecting DRE and contributed the most to the model accuracy (0.83) than clinical features. Resting-state EEG activity of HS and PwE did not deviate from the characteristics of a system operating at criticality.

CONCLUSIONS

ATMs detect alterations of resting-state networks peculiar to the DRE condition.

SIGNIFICANCE

These findings could open new scenarios for the future identification of promising biomarkers of DRE through scalp EEG.

Prevalence of depression in people with epilepsy: A hospital-based study in Cameroon

INTRODUCTION

depression is a psychiatric disorder present in many chronic diseases with varying prevalences. In people with epilepsy (PWE), it represents the most frequent psychiatric comorbidity associated with impaired quality of life, and increased risk of suicide. The aim of this research was to determine the prevalence and factors associated with depression in PWE.

METHODS

this was a cross-sectional study with an age- and sex- matched control group, conducted between February 12 and May 15, 2024, in two referral hospital of Douala. It included individuals (PWE and controls) aged 18 years and older who agreed to participate in the study. Individuals (PWE and controls) with a serious general health problem that could have a significant impact on mental status (hypertension, HIV, diabetes, renal failure, heart failure, dementia, bipolar disorder) or an inability to communicate were excluded. Recruitment was done through an online and in-person survey using a form. We collected sociodemographic data, and data on epilepsy in PWE. Depression was evaluated using the PHQ-9 scale. We used the Generalized Anxiety Disorder Questionnaire (GAD-7) to assess anxiety disorders. Univariate and multivariate analysis (binary logistic regression) were used to identify the factors significantly associated with depression in PWE. The significance threshold was considered for a value of p < 0.05.

RESULTS

a total of 633 individuals, including 211 PWE, were included in the study. The prevalence of depression was significantly higher in PWE (24.6 %) compared to controls (11.8 %) (OR: 2.0, 95 %CI: 1.433-2.905, p < 0.001). Anxiety disorders was significantly higher in PWE (OR: 1.6, 95 %CI: 1.101-2.397, p = 0.014). Factors independently associated to depression were female sex (OR: 2.7, 95 %CI: 1.115-6.343, p = 0.027), suicidal ideation (OR: 5.8, 95 %CI: 2.083-16.174, p = 0.001), and anxiety disorders (OR: 10.2, 95 %CI: 4.023-25.748, p < 0.001).

CONCLUSION

the prevalence of depression is high in PWE compared to controls in Douala. A systematic screening should be included in the follow-up of PWE.

Cenobamate modulates EEG cortical activity and connectivity in individuals with drug-resistant epilepsy: a pharmaco-EEG study

Objective

Quantitative electroencephalography (qEEG) metrics are demonstrated to correlate with and predict clinical response in individuals with epilepsy. Cenobamate is an effective anti-seizure medication recently approved as an add-on therapy for individuals with epilepsy, but its effects on qEEG are unknown. We aimed to evaluate the modulation of qEEG metrics induced by cenobamate and its relationship with clinical response.

Methods

We performed a prospective study with a cohort of 18 individuals with epilepsy (8 women, 47 ± 16 years old) and 25 healthy subjects (HS). They underwent a 19-channel EEG before and 6 months after cenobamate administration. Power spectral density (PSD) and phase locking value (PLV) for delta, theta, alpha, beta, and gamma frequency bands were calculated. Correlation analysis and analysis of covariance exhibited significant cenobamate-induced changes in qEEG and their relationship with seizure frequency changes. A regression analysis was performed to evaluate the association with clinical responders.

Results

A total of 11 out of 16 individuals with epilepsy (69%, with 2 dropping out) were cenobamate responders (≥50% seizure frequency reduction). Cenobamate did not modify any PSD parameter but induced significant changes in PLV levels (p < 0.01). A decrease in PLV correlated with seizure reduction (p < 0.03). Regression analysis showed a strong association between PLV modulation and cenobamate responsiveness (a sensitivity of 0.75, a specificity of 0.84, and an accuracy of 0.81).

Conclusion

Cenobamate induces an EEG connectivity modulation that is highly associated with cenobamate clinical response.

Significance

Connectivity analysis of pharmaco-EEG can provide new hints toward the development of innovative biomarkers and precision medicine in individuals with epilepsy.

Seizure freedom and reducing the risk of sudden unexpected death in patients with focal epilepsy treated with cenobamate or other antiseizure medications

People with epilepsy who have uncontrolled seizures are at increased risk of all-cause mortality, injuries, comorbidities, mood and psychosocial disorders, and diminished quality of life. For those with focal epilepsy, focal to bilateral tonic-clonic seizures (FBTCS) pose the greatest risk for sudden unexpected death in epilepsy (SUDEP), a leading cause of premature mortality in people with epilepsy. Cenobamate is a third-generation antiseizure medication with demonstrated efficacy in controlling focal seizures, including FBTCS, in people with drug-resistant epilepsy. Treatment with cenobamate in clinical trials was associated with a reduction in all-cause mortality to a rate statistically indistinguishable from that seen in the general population, and SUDEP rates were lower than expected. As FBTCS are associated with the highest risk of death, prevention of this seizure type is especially important, and physicians should continue to try new therapies to prevent these seizures. A shared decision-making model should be used when interacting with patients and their care providers to achieve and maintain seizure control and maximize treatment outcomes.

Epilepsy medication management: Addressing common treatment barriers to adopting cenobamate and other new antiseizure medications

Seizure freedom is an important therapeutic goal for people with epilepsy and is associated with improved quality of life and reduced morbidity and mortality. Yet despite the use of multiple antiseizure medications (ASMs; either as monotherapy or in combination), seizures persist in approximately one third of patients. Third-generation ASMs, such as lacosamide, eslicarbazepine, perampanel, and brivaracetam, have demonstrated good efficacy in terms of reductions in the frequency of focal seizures. The newest ASM, cenobamate, which is indicated for the treatment of focal seizures in adults, has demonstrated notable rates of seizure freedom for some patients with drug-resistant epilepsy. In long-term, open-label clinical studies of adjunctive cenobamate, between 18.4% and 36.3% of patients achieved seizure freedom for a consecutive ≥12-month duration, and 1-year retention rates ranged from 73% to 83%. This article reviews some of the potential treatment barriers encountered during the medication management of patients with epilepsy that may impede the use and optimization of newer ASMs like cenobamate. These include treatment complacency, inadequate trial of new adjunctive therapies ("last in, first out"), pitfalls of rational polytherapy, and restricting the use of newer drugs. Although treatment must always be tailored to the specific patient, clinicians should consider the potential benefits of newer therapies and continue to reassess and optimize ASM treatment to achieve the best outcomes for their patients.

Impact of interaction among antiseizure medication polytherapy, clinical, sociodemographic and psychological factors on quality of life in patients with epilepsy: A systematic review

INTRODUCTION

Drug-resistant epilepsy usually requires the use of polytherapy with antiseizure medications (ASMs) for management, which could involve side and adverse effects that may impact quality of life (QOL). This systematic review summarizes the evidence about the relationship between ASM polytherapy and QOL in epilepsy patients, considering clinical, sociodemographic, and psychological variables.

METHOD

This review followed the PRISMA guidelines and was registered in PROSPERO. The studies examined were collected from PubMed/MEDLINE, Scopus, Web of Science, and Embase. The data extracted were categorized into three categories: therelationship between the number of ASMs and QOL, differences in QOL between patients taking polytherapy and patients taking monotherapy, and therole of other variables on QOL.

RESULTS

The review included 34 studies. Thirty examined the relationship between the number of ASMs and QOL, 93.3% of them identifying a significant association between a higher number of ASMs and poorer QOL. Fifteen studies analyzed differences in QOL between patients receiving polytherapy and those on monotherapy, all of them showing poorer QOL in those on polytherapy. Thirty-two studies considered other factors beyond polytherapy as determinants of QOL, including clinical, sociodemographic, and psychological variables, and higher seizure frequency and mood comorbidities (depression and anxiety) emerged as the strongest predictors of poor QOL.

CONCLUSIONS

Polytherapy, despite being necessary for managing drug-resistant epilepsy, significantly contributes to impairing QOL. Effective seizure control remains critical, but a multifactorial approach addressing mental health and social determinants is essential for improving QOL in epilepsy patients. Future research should focus on optimizing treatment strategies that balance seizure control by minimizing the negative impact of polytherapy.

The Cost-Effectiveness of Seizure Dogs for Persons Living With Severe Refractory Epilepsy: Results From the EPISODE Study

OBJECTIVES

The Epilepsy Support Dog Evaluation study was commissioned by the Dutch Ministry of Health, Welfare and Sports to inform a reimbursement decision on seizure dogs. The randomized trial found that seizure dogs reduce seizure frequency and improve health-related quality of life of persons with severe refractory epilepsy (PSREs). This article examined the cost-effectiveness (CE) of adding seizure dogs to usual care for PSREs in The Netherlands.

METHODS

A microsimulation model was developed, informed by generalized linear mixed models using patient-level trial data from the Epilepsy Support Dog Evaluation study. The model adopted a 10-year time horizon and took a societal perspective. Seizure frequency was predicted as a function of time with the seizure dog. Patient utilities, caregiver utilities, and costs were predicted as a function of seizure frequency and time with the seizure dog.

RESULTS

Quality-adjusted life-years (QALYs) of PSREs with a seizure dog and usual care alone were estimated at 6.28 and 5.65, respectively (Δ 0.63). For caregivers, estimated QALYs were 6.94 and 6.52, respectively (Δ 0.42). Total costs were respectively €228 691 and €226 261 (Δ €2430). Intervention costs were largely offset by savings in informal care and healthcare. The incremental CE ratio was €2314/QALY. Probabilistic sensitivity analysis indicated a 91% probability of seizure dogs being cost-effective at the €50 000/QALY threshold. The incremental CE ratio fell well below this threshold in scenario analyses.

CONCLUSIONS

Seizure dogs are likely to be a cost-effective addition to usual care for PSREs in The Netherlands.

N-of-1 trials in epilepsy: A systematic review and lessons paving the way forward

OBJECTIVE

Defined as prospective single-patient crossover studies with repeated paired cycles of active and control intervention, N-of-1 trials have gained attention as an option to obtain high-quality evidence of efficacy, particularly for patients with rare epilepsies in whom conduction of well-powered randomized controlled trials can be challenging. The objective of this systematic review is to provide an appraisal of the literature on N-of-1 trials in individuals with epilepsy.

METHODS

We searched PubMed and Embase on January 12, 2024, for studies meeting the following criteria: prospectively planned, within-patient, multiple-crossover design in individuals with epilepsy and outcomes related to comorbidities. Information on design, outcome measurements, intervention, and analyses was retrieved. Risk of bias assessment was performed using the Risk of Bias in N-of-1 Trials (RoBiNT) scale. We highlighted methodological aspects of the N-of-1 trials identified and discuss future recommendations.

RESULTS

Five studies met our inclusion criteria. An additional multiple-crossover trial that evaluated treatment effects exclusively at group level was also included because of its relevance to N-of-1 study methodology. The studies enrolled individuals with focal seizures, absences or cognitive impairement and electrographic discharges. Treatments included established or investigational antiseizure medications, off-label medications, neurostimulation or lifestyle intervention. Three of the five N-of-1 trials reported on individual cases. The studies' strengths were the use of individualized treatment dosages and symptom-specific patient-reported outcomes. Limitations were related to minimal reporting of baseline characteristics and seizure burden.

SIGNIFICANCE

The trials identified by our search exemplify how the N-of-1 design can be applied to assess interventions in individuals with epilepsy-related disorders. Future N-of-1 trials of antiseizure interventions should take into account baseline seizure frequency, should apply statistical models suited to capture seizure frequency changes reliably and make predefined interim assessments. Non-seizure outcome measures evaluable over short periods should be considered. Tailored N-of-1 methodology could pave the way to evidence-based, treatment selection for patients with rare epilepsies.

Intraparenchymal delivery of adeno-associated virus vectors for the gene therapy of neurological diseases

INTRODUCTION

In gene therapy with adeno-associated virus (AAV) vectors for diseases of the central nervous system, the vectors can be administered into blood vessels, cerebrospinal fluid space, or the brain parenchyma. When gene transfer to a large area of the brain is required, the first two methods are used, but for diseases in which local gene transfer is expected to be effective, vectors are administered directly into the brain parenchyma.

AREAS COVERED

Strategies for intraparenchymal vector delivery in gene therapy for Parkinson's disease, aromatic l-amino acid decarboxylase (AADC) deficiency, and epilepsy are reviewed.

EXPERT OPINION

Stereotactic intraparenchymal injection of AAV vectors allows precise gene delivery to the target site. Although more surgically invasive than intravascular or intrathecal administration, intraparenchymal vector delivery has the advantage of a lower vector dose, and preexisting neutralizing antibodies have little effect on the transduction efficacy. This approach improves motor function in AADC deficiency and led to regulatory approval of an AAV vector for the disease in the EU. Although further validation through clinical studies is needed, direct infusion of viral vectors into the brain parenchyma is expected to be a novel treatment for Parkinson's disease and drug-resistant epilepsy.

The Most Frequent Psychiatric Comorbidities in Bulgarian Patients With Epilepsy: Their Connection With the Main Clinical Characteristics and Quality of Life

AIM

 The objective of this study is to determine and compare the relationship of the most common psychiatric comorbidities in Bulgarian patients with epilepsy with the main clinical characteristics, as well as to evaluate their impact on certain aspects of the quality of life.

CLINICAL RATIONALE

 Psychiatric comorbidities occur in about one-third of people with epilepsy throughout their lifetime, and their incidence is much greater in high-risk groups such as patients with treatment-resistant epilepsy.

MATERIAL AND METHODS

 The study group consisted of 129 participants, of whom 104 were divided into four groups according to the presence of one of the most frequently diagnosed psychiatric comorbidities in our patients with epilepsy: personality and behavioral disorder (PBD) (n=25), mild to moderate depressive disorder (n=26), anxiety disorder (n=32), and dissociative and conversion disorders (n=21). A control group was also formed with a similar number of participants with epilepsy (n=25) without psychiatric comorbidity. Some sociodemographic and clinical characteristics of epilepsy were analyzed in all patients. All patients filled out two questionnaires: the Bulgarian version of quality of life in epilepsy - 89 (QOLIE-89) and the Bulgarian version of SIDAED (assessing SIDe effects in antiepileptic drugs (AED) treatment).

RESULTS

 The analysis revealed a negative influence of psychiatric comorbidity on the presence of epileptic seizures, unwanted drug effects, and lower scores for all aspects of the quality of life of patients with epilepsy.

CONCLUSION AND CLINICAL IMPLICATIONS

 The main conclusion of our study is the presence of an interaction between psychiatric comorbidity, the clinical course of the disease, and the deteriorated quality of life (QOL) in patients with epilepsy. Further attention, comprehensive care, and targeted research are needed to analyze individual psychiatric comorbidities in patients with epilepsy for early detection and treatment.

Factors influencing quality of life in extratemporal lobe epilepsy and mesial temporal lobe epilepsy: a cross-sectional study using medical records

Objective

This study aimed to examine differences in factors influencing quality of life (QOL) in people with extratemporal lobe epilepsy (ETLE) and mesial temporal lobe epilepsy (MTLE).

Methods

We obtained data from the medical records of 84 (47 ETLE and 37 MTLE) people with epilepsy. The data included age, sex, employment, seizure frequency, number of antiseizure medication (ASM), Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) score, and Quality of Life in Epilepsy Inventory-31 (QOLIE-31) score. Multiple regression analyses were performed using QOLIE-31 as the dependent variable and age, sex, employment, seizure frequency, number of ASM, and NDDI-E score as the independent variables in ETLE or MTLE.

Results

From the results of the multiple regression analyses, QOLIE-31 in ETLE was associated with NDDI-E (β = -0.757, p < 0.001) and employment (β = 0.388, p = 0.008). Meanwhile, QOLIE-31 in MTLE was associated with NDDI-E (β = -0.625, p < 0.001), employment (β = 0.396, p = 0.041), and number of ASMs (β = -0.399, p = 0.018).

Conclusion

Overall, our findings indicate that the number of ASMs is potentially an influence on QOL of MTLE but similar effect is not observed in ETLE.

Postictal psychiatric symptoms: A neurophysiological study

OBJECTIVE

Postictal psychiatric symptoms (PPS) are a relatively common but understudied phenomenon in epilepsy. The mechanisms by which seizures contribute to worsening in psychiatric symptoms are unclear. We aimed to identify PPS prospectively during and after admission to the epilepsy monitoring unit (EMU) in order to characterize the postictal physiologic changes leading to PPS.

METHODS

We prospectively enrolled patients admitted to the EMU and administered repeat psychometric questionnaires during and after their hospital stay in order to assess for postictal exacerbations in four symptom complexes: anger/hostility, anxiety, depression, and paranoia. Electroclinical and electrographic seizures were identified from the EEG recordings, and seizure durations were measured. The severity of postictal slowing was calculated as the proportion of postictal theta/delta activity in the postictal EEG relative to the preictal EEG using the Hilbert transform.

RESULTS

Among 33 participants, 8 demonstrated significant increases in at least one of the four symptoms (the PPS+ group) within three days following the first seizure. The most common PPS was anger/hostility, experienced by 7/8 participants with PPS. Among the 8 PPS+ participants, four experienced more than one PPS. As compared to those without PPS (the PPS- group), the PPS+ group demonstrated a greater degree of postictal EEG slowing at 10 min (p = 0.022) and 20 min (p = 0.05) following seizure termination. They also experienced significantly more seizures during the study period (p = 0.005). There was no difference in seizure duration between groups.

SIGNIFICANCE

Postictal psychiatric symptoms including anger/hostility, anxiety, depression, and paranoia may be more common than recognized. In particular, postictal increases in anger and irritability may be particularly common. We provide physiological evidence of a biological mechanism as well as a demonstration of the use of quantitative electroencephalography toward a better understanding of postictal neurophysiology.

Add-on treatment with cenobamate is already effective at low doses in refractory focal epilepsy: A prospective observational study

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.

Clinical outcome assessment in patients with epilepsy: The value of health-related quality of life measurements

This narrative review provides an overview of the current knowledge on health-related quality of life (HRQOL), a relevant clinical outcome in patients with epilepsy. It shows that the most important factor determining HRQOL in this patient group is seizure frequency. In particular, seizure-freedom is associated with better HRQOL scores. Many other factors may impact perceived HRQOL aspects, but their interrelation is complex and requires further research. Novel analytical approaches, such as hierarchical cluster and symptom network analyses might shed further light on this, and may result in recommendations for interventions on the most 'central' factors influencing different aspects of HRQOL in patients with epilepsy. Next, an overview of the HRQOL tools and analytical methods currently used in epilepsy care, with a focus on clinical trials, is provided. The QOLIE-31 is the most frequently applied and best validated tool. Several other questionnaires focusing on specific aspects of HRQOL (e.g., mood, social impact) are less frequently used. We show some pitfalls that should be taken into account when designing study protocols including HRQOL endpoints. This includes standardized statistical analysis approaches and predefined reporting methods for HRQOL in epilepsy populations. It has been shown in other patient groups that the lack of such standardisation negatively impacts the quality and comparability of results. We conclude with a number of recommendations for future research.

Health-related quality of life in epilepsy and its associated factors among adult patients with epilepsy attending Mizan Tepi University Teaching Hospital, Southwest Ethiopia: a cross-sectional study

OBJECTIVE

To determine the mean score of health-related quality of life in epilepsy and its associated factors among adult patients with epilepsy.

DESIGN

Institution-based cross-sectional study based on random case selection was conducted.

SETTING

The study was carried out at Mizan-Tepi University Teaching Hospital located in Southwest Ethiopia.

PARTICIPANTS

A total of 346 patients with epilepsy who visited the psychiatric clinic for follow-up for at least 3 months and who were 18 years or older were included in the study.

MAIN OUTCOME MEASURE

Health-related quality of life in epilepsy measured using quality-of-life in epilepsy (QOLIE)-31 health survey evaluated as a dependent variable with simple and multivariable linear regressions.

RESULTS

The overall weighted mean score of health-related quality of life was 55.6 (SD=20.9). Only 50.3% of patients scored above a total score of 50. Age (β=-0.35, 95% CI-0.46 to -0.23), anxiety (β=-6.79, 95% CI -9.26 to -4.32), depression (β=-7.36, 95% CI -10.16 to -4.55), low self-esteem (β=-5.29, 95% CI -8.07 to -2.51), perceived stigma (β=-3.62, 95% CI -6.30 to -0.94), taking medication two times or more times per day (β=-2.4, 95% CI -4.58 to -0.27), being illiterate (β=-4.1, 95% CI -6.87 to -1.31) and having more than two seizures for a year (β=-4.18, 95% CI -6.97 to -1.39) were negatively affecting health-related quality of life while income of >1000 birr per month (β=4.5, 95% CI 2.00 to 6.99), social support (β=0.34, 95% CI 0.27 to 0.40) and being free of seizure for a year (β=6.5, 95% CI 3.66 to 9.33) were positively affecting health-related quality of life.

CONCLUSIONS

Only half of the patients with epilepsy in the study area are leading a better quality of life and the overall mean health-related quality of life score is lower than the global mean score. Health-related quality of life was inversely associated with age, anxiety, depression, low self-esteem, perceived stigma, taking medication two times a day or more, being illiterate and experiencing more than two seizures in a year. Besides controlling seizures, public educational campaigns should be conducted to raise public awareness regarding the need for social support.

Prevalence and nature of patient-reported antiseizure medication side effects in a Swedish regional multi-center study

PURPOSE

Side effects is one of the major clinical problems in epilepsy care. We assessed the prevalence of ASM side effects in participants in a large regional multicenter observational study in western Sweden and aimed to identify risk factors and inventory the nature of side effects with different ASM regimes.

METHODS

Cross-sectional analysis of survey answers and clinical characteristics of 406 adult participants recruited to a regional observational study between December 2020 and March 2023. Half of the participants had been seizure free for one year. Second-generation or newer ASMs were the most common.

RESULTS

A total of 164 (40 %, 95 %CI: 36-45) patients reported side effects. Patients reporting side effects were younger (median 41 vs 47 years, p = 0.015), had more frequently experienced a seizure in the last year (p = 0.02), and were more often on ASM polytherapy (p < 0.01). ASM polytherapy and age were significant risk factors in regression models, but the explanatory value was low. The most common side effect was tiredness followed by cognitive symptoms.

CONCLUSIONS

Our findings show that side effects are still common in epilepsy care and suggests that unnecessary polypharmacy should be avoided. Apart from number or ASMs, predicting who will experience side effects is difficult and more research on individual vulnerability is needed.

Development and evaluation of a virtual reality driving test for patients with cirrhosis

BACKGROUND

Patients with cirrhosis and especially those with HE may have impaired driving skills and may be prone to car accidents. This proof-of-concept study aimed to develop and evaluate the applicability of a virtual reality (VR)-based driving test in patients with cirrhosis. Additionally, the association between the results in the VR test and car accidents was investigated.

METHODS

A short driving test using a VR head-mounted display (HTC Vive Pro Eye) was developed to simulate five hazardous situations. The patient has to pull the brake when the hazardous situations occur. The time from triggering the event to pressing the brake is recorded as reaction time. Total reaction time (TRT) is defined as the combined reaction time to all 5 events. Car accidents were assessed retrospectively (previous 12 months) and patients were followed prospectively for 6 months. Minimal HE (MHE) was diagnosed using Psychometric Hepatic Encephalopathy Score.

RESULTS

In total, 112 outpatients with cirrhosis and 52 controls without cirrhosis were recruited. MHE was detected in 14% (n = 15). Patients with cirrhosis and MHE (5.67 s) had higher TRTs compared to patients without MHE (5.02 s) and controls without cirrhosis above the age of 50 (4.98 s) (MHE vs. no MHE or controls p<0.01, no MHE vs. controls: not significant). Seven patients reported car accidents during the twelve months prior to study inclusion. TRTs were numerically higher in patients with reported car accidents (p = 0.099). When patients who stopped driving for HE-related/cirrhosis-related reasons (n = 14) were added to the group of patients with accidents, then a longer TRT was significantly associated with the modeled outcome in univariable (p<0.01) and multivariable analyses (OR 2.83, p<0.01). Two car accidents occurred during follow-up. Both patients had TRTs above the 90th percentile.

CONCLUSIONS

The VR driving test is easy and rapid to perform in patients with cirrhosis and could be helpful as a point-of-care tool for predicting car accidents.

Dose reduction and discontinuation of concomitant antiseizure medications after initiating cenobamate: A retrospective review

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.

First add-on lacosamide treatment in children with focal epilepsy in China: A multi-centre real-life cohort study

AIM

To assess the effectiveness and safety of lacosamide (LCM) as the first add-on therapy for children with focal epilepsy at multiple centres in China.

METHOD

Children aged 4-16 years with focal epilepsy from 13 epilepsy centres were included in this study. All patients were treated with LCM as the first add-on treatment and followed up for 26 weeks. The seizure frequency, seizure-free rate, ≥50% response rate, retention rate, and incidence of adverse drug reactions after the addition of LCM were analysed.

RESULTS

Ninety-nine children (58 males; aged 4-16 years; mean age 8.51 ± 2.95 years) were enroled. The mean age at first seizure was 5.74 ± 3.12 years. All patients were administered LCM as the first add-on treatment for focal epilepsy. Twenty-eight patients (28/99, 28.28%) did not experience seizures during the follow-up period. The ≥50% response rates were 80.81% (80/99), 93.88% (92/98), 98.98% (97/98), and 100.0% (98/98) at 6 weeks (visit two), 10 weeks (visit three), 18 weeks (visit four), and 26 weeks (visit five), respectively, compared to that at baseline (visit one). The intelligence scores decreased in 12 participants, remained unchanged in 64, and increased in 16. Adverse events occurred in three participants during the trial, all of which were mild.

INTERPRETATION

LCM was effective as the first add-on therapy in this real-life multi-centre study of a paediatric population with focal epilepsy. Further prospective studies with long-term follow-up periods are needed to confirm the effectiveness and tolerability of LCM.

Resilience predicts and modulates anxiety severity in people with epilepsy

BACKGROUND

Anxiety is one of the most relevant psychiatric comorbidities in people with epilepsy (PwE). The role of resilience (RES) in the development of anxiety is not well understood. We purposed to better characterize RES impact on anxiety severity in PwE.

MATERIALS AND METHODS

One hundred and seventy-six PwE underwent online surveys including a collection of socio-demographic, seizure-related, and psychological variables. PwE were grouped according to the data collected; anxiety levels were compared through non-parametric statistics. Hierarchical regression analysis (HRA) and logistic regression were performed to characterize RES contribute in predicting the presence and the severity of anxiety. Mediation/moderation analysis was performed to evaluate causal effects among RES, depression, and anxiety.

RESULTS

Anxiety did not differ according to socio-demographic and seizure-related variables, exemption for the presence of drug-related adverse effects. Depression, RES, and sleep quality provided the major contribute on anxiety variance. The addiction of RES level in HRA and logistic regression provided a significant increase of R-squared value (p-value = 0.02) and of area under the curve (p-value = 0.03), respectively. RES modulated depression/anxiety relationship (p-value < 0.001), whereas depression did not mediate RES/anxiety correlation (p-value = 0.68).

CONCLUSIONS

We demonstrated that RES is a significant independent predictor of anxiety in PwE and is able to modulate depression impact on anxiety. Moreover, we confirmed the relevance of depression and sleep quality on anxiety severity.

Drug resistance in epilepsy

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.

Clinical relevance of interictal dysphoric disorder and its impact on quality of life in drug-resistant epilepsy

OBJECTIVE

This study aims to assess the prevalence of Interictal Dysphoric Disorder (IDD) in drug-resistant epilepsy (DRE) and to describe its clinical and psychopathological profile, including personality, as well as its impact on quality of life (QOL).

METHOD

A retrospective cross-sectional study from an Epilepsy Unit from January 2007 to December 2017. All patients were diagnosed with DRE. Patients underwent a battery of tests (HADS, SCL-90R, PDQ-4+, QOLIE-31) and a psychiatrist assessed the presence of Axis-I disorders and IDD. Statistical procedures were carried out using R-4.0.1 software.

RESULTS

A total of 282 patients were included. A statistically significant association was found between IDD and mood and anxiety disorders (p < 0.001 and p < 0.05 respectively), and between IDD and higher scores in all HADS and SCL-90-R items compared to subjects without IDD (p < 0.001). A statistically significant association was also found between IDD and obsessive-compulsive, borderline and depressive personality disorder (p < 0.05). Scores in all QOLIE-31 items except for 'medication effects' were significantly lower in subjects with IDD compared with subjects without IDD (p < 0.001).

CONCLUSIONS

In DRE, IDD subjects show differences in the psychopathological profile and QOL scores compared to subjects without a diagnosis of IDD. An early diagnosis of IDD could facilitate prompt interventions which might positively impact QOL.

Somatic symptoms and related disorders in a large cohort of people with epilepsy: A cohort study

OBJECTIVE

This study was undertaken to characterize somatic symptoms and related disorders (SSD) in epilepsy.

METHODS

Adults with epilepsy under active follow-up at a tertiary epilepsy center were consecutively enrolled. The diagnosis of SSD was performed by an experienced psychologist based on the structured clinical interview for Statistical Manual of Mental Disorders, 5th edition. Detailed social/demographic data, epilepsy features, psychiatric features, life quality, disability, and economic burden were collected and compared between people with SSD and those without. Bodily distress syndrome checklist, Somatic Symptom Disorder-B Criteria Scale, Patient Health Questionnaire-9, and Generalized Anxiety Disorder seven-item scale (GAD-7) were used to evaluate SSD individuals' somatic symptoms, symptom-related psychological distress, and depressive and anxious symptoms. Quality of life and disability were assessed by Quality of Life in Epilepsy Inventory 31 (QOLIE-31) and World Health Organization Disability Assessment Schedule V.2.0 (WHO DAS 2.0). A risk prediction nomogram was generated using least absolute shrinkage and selection operator (LASSO) analysis and validated.

RESULTS

One hundred fifty of 631 participants (24%) were diagnosed with SSD. In people with SSD, the top three most common somatic symptoms were memory impairment, headache, and dizziness (85%, 80%, and 78%, respectively), and multiple systems were involved in most (82%) people with SSD. Compared with people without SSD, those with SSD had lower QOLIE-31 total scores, and higher WHO DAS 2.0 scores and disease economic burdens. LASSO analysis suggested that a history of severe traumatic brain injury, hippocampal sclerosis, low seizure worry and medication effects scores on QOLIE-31, multiple systems affected by somatic symptoms, and a high GAD-7 score were risk factors of SSD. The nomogram was validated for good accuracy in the training and testing cohorts.

SIGNIFICANCE

SSD are likely to be a common comorbidity in epilepsy and harm epilepsy prognosis. Our risk prediction nomogram was successfully developed but needs further validation in larger cohorts.

Autonomic dysfunction in epilepsy mouse models with implications for SUDEP research

Epilepsy has a high prevalence and can severely impair quality of life and increase the risk of premature death. Sudden unexpected death in epilepsy (SUDEP) is the leading cause of death in drug-resistant epilepsy and most often results from respiratory and cardiac impairments due to brainstem dysfunction. Epileptic activity can spread widely, influencing neuronal activity in regions outside the epileptic network. The brainstem controls cardiorespiratory activity and arousal and reciprocally connects to cortical, diencephalic, and spinal cord areas. Epileptic activity can propagate trans-synaptically or via spreading depression (SD) to alter brainstem functions and cause cardiorespiratory dysfunction. The mechanisms by which seizures propagate to or otherwise impair brainstem function and trigger the cascading effects that cause SUDEP are poorly understood. We review insights from mouse models combined with new techniques to understand the pathophysiology of epilepsy and SUDEP. These techniques include in vivo, ex vivo, invasive and non-invasive methods in anesthetized and awake mice. Optogenetics combined with electrophysiological and optical manipulation and recording methods offer unique opportunities to study neuronal mechanisms under normal conditions, during and after non-fatal seizures, and in SUDEP. These combined approaches can advance our understanding of brainstem pathophysiology associated with seizures and SUDEP and may suggest strategies to prevent SUDEP.

Minimally Invasive Destructive, Ablative, and Disconnective Epilepsy Surgery

Conventional epilepsy surgery performed by microsurgical dissection typically requires large cranial working windows created with high-speed drills and lengthy incisions. In the past few decades, minimally invasive techniques have been developed with smaller incisions, comparable efficacy, shorter hospitalizations, and better safety profiles. These minimally invasive alternatives utilize stereotactic, ultrasonic, radiotherapeutic, and endoscopic techniques. Although not able to completely replace conventional surgery for all etiologies of epilepsy, these minimally invasive techniques have revolutionized modern epilepsy surgery and have been an invaluable asset to the neurosurgeon's repertoire. The endoscope has allowed for surgeons to have adequate visualization during resective and disconnective epilepsy surgeries using keyhole or miniature craniotomies. Modern stereotactic techniques such as laser interstitial thermal therapy and radiofrequency ablation can be used as viable alternatives for mesial temporal lobe epilepsy and can destroy lesional tissue deep areas without the approach-related morbidity of microsurgery such as with hypothalamic hamartomas. These stereotactic techniques do not preclude future surgery in the settings of treatment failure and have been used successfully after failed conventional surgery. Multiple ablation corridors can be performed in a single procedure that can be used for lesioning of large targets or to simplify treating multifocal epilepsies. These stereotactic techniques have even been used successfully to perform disconnective procedures such as hemispherotomies and corpus callosotomies. In patients unable to tolerate surgery, stereotactic radiosurgery is a minimally invasive option that can result in improved seizure control with minimal procedural risks. Advances in minimally invasive neurosurgery provide viable treatment options for drug-resistant epilepsy with quicker recovery, less injury to functional brain, and for patients that may otherwise not choose conventional surgery.

Cognitive decline and quality of life after resective epilepsy surgery

OBJECTIVES

The objectives of this study were to examine the association between cognitive decline and quality of life (QoL) change in a large sample of individuals with drug-resistant epilepsy who underwent resective surgery and to examine whether the association between cognitive decline and QoL is differentially affected by seizure classification outcome (Engel Class 1 vs. 2-4) or side of surgery (left vs. right hemisphere).

MATERIALS AND METHODS

The sample comprised 224 adults (ages ≥ 18) with drug-resistant focal epilepsy treated with resective surgery who underwent comprehensive pre-operative and post-operative evaluations including neuropsychological testing and the Quality of Life in Epilepsy Inventory - 31 between 1991 and 2020. Linear mixed-effects models were fit to examine subject-specific trajectories and assess the effects of time (pre- to post-operative), cognitive decline (number of measures that meaningfully declined), and the interaction between time and cognitive decline on pre- to post-operative change in QoL.

RESULTS

Increases in QoL following resection were observed (B = -10.72 [SE = 1.22], p < .001; mean difference between time point 1 and time point 2 QoL rating = 8.11). There was also a main effect of cognitive decline on QoL (B = -.85 [SE = .27], p = .002). Follow-up analyses showed that the number of cognitive measures that declined was significantly associated with post-surgical QoL, (r = -.20 p = .003), but not pre-surgical QoL, (r = -.04 p = .594), and with pre-to post-surgery raw change in QoL score, (r = -.18 p = .009). A cognitive decline by time point interaction was observed, such that those who had greater cognitive decline had less improvement in overall QoL following resection (B = .72 [SE = .27], p = .009). Similar results were observed within the Engel Class 1 outcome subgroup. However, within the Engel Class 2-4 outcome subgroup, QoL improved following resection, but there was no main effect of cognitive decline or interaction between cognitive decline and time point on QoL change. There was no main effect of resection hemisphere on overall QoL, nor were there interactions with hemisphere by time, hemisphere by cognitive decline, or hemisphere by time by cognitive decline.

CONCLUSIONS

Quality of life improves following epilepsy surgery. Participants who had cognitive decline across a greater number of measures experienced less improvement in QoL post-operatively overall, but there was no clear pattern of domain-specific cognitive decline associated with change in QoL. Our results indicate that cognitive decline in a diffuse set of cognitive domains negatively influences post-operative QoL, particularly for those who experience good seizure outcomes (i.e., seizure freedom), regardless of the site or side of resection.

Mapping analysis to predict SF-6D utilities from health outcomes in people with focal epilepsy

BACKGROUND

Focal-onset seizures (FOS) are commonly experienced by people with epilepsy and have a significant impact on quality of life (QoL). This study aimed to develop a mapping algorithm to predict SF-6D values in adults with FOS for use in economic evaluations of a new treatment, cenobamate.

METHODS

An online survey, including questions on disease history, SF-36, and an epilepsy-specific measure (QOLIE-31-P) was administered to people with FOS in the UK, France, Italy, Germany, and Spain. A range of regression models were fitted to SF-6D scores including direct and response mapping approaches.

RESULTS

361 individuals were included in the analysis. In the previous 28 days, the mean number of FOS experienced was 3, (range 0-43) and the mean longest period of consecutive days without experiencing a seizure was 14 days (range 1-28 days or more). Mean responses on all SF-36 dimensions were lower than general population norms. Mean SF-6D and QOLIE-31-P scores were 0.584 and 45.72, respectively. The best performing model was the ordinary least squares (OLS), with root mean squared error and mean absolute error values of 0.0977 and 0.0742, respectively. Explanatory variables which best predicted SF-6D included seizure frequency, severity, freedom, and age.

CONCLUSION

People with uncontrolled FOS have poor QoL. The mapping algorithm enables the prediction of SF-6D values from clinical outcomes in people with FOS. It can be applied to outcome data from clinical trials to facilitate cost-utility analysis.

Dose Adjustment of Concomitant Antiseizure Medications During Cenobamate Treatment: Expert Opinion Consensus Recommendations

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.

Effects of insomnia and levels of depression and anxiety symptoms on quality of life in people with epilepsy

OBJECTIVES

The association between insomnia and quality of life (QOL) in epilepsy is poorly understood and may involve interactive variables. We aimed to investigate whether and how insomnia, levels of depression and anxiety symptoms interact to influence QOL in people with epilepsy (PWE).

METHODS

A consecutive cohort of 179 PWE was enrolled. We collected data on insomnia, levels of depression and anxiety symptoms, and QOL. The Insomnia Severity Index (ISI), Depression Inventory for Epilepsy (NDDI-E), Generalized Anxiety Disorder-7 (GAD-7), and QOL in Epilepsy Inventory (QOLIE-31) were used. The direct, indirect, and total effects of insomnia on QOL were estimated based on a moderated mediation model.

RESULTS

Depression symptom levels mediated the association between insomnia and QOL (B = 0.09 SE = 0.03, p = 0.01). Depression symptom levels accounted for 34.7% of the total effect of insomnia on QOL. The mediating effect of depression symptom levels was positively moderated by anxiety symptom levels (B = 0.09, SE = 0.03, p = 0.01).

CONCLUSION

The effect of insomnia on QOL can be partially explained by the mediation of depression symptom levels. Additionally, improving anxiety symptoms may attenuate the indirect effect of insomnia on QOL through depression symptom levels.

Quality of life in patients with symptomatic epilepsy due to neurocysticercosis

BACKGROUND

Neurocysticercosis (NCC) is a common cause of late-onset epilepsy worldwide, but there is still minimal information regarding its impact on a patient's quality of life. This study evaluated quality of life in a series of patients with epilepsy secondary to NCC using the QOLIE (Quality of Life in Epilepsy)-31 questionnaire.

METHODOLOGY

This cross-sectional study included 155 Peruvian patients between 16 and 70 years of age with epilepsy due to viable intraparenchymal NCC, who enrolled in two trials of anti-parasitic treatment during the period 2006-2011. The QOLIE-31 questionnaire was applied before the onset of anti-parasitic treatment. The associations between QOLIE-31 scores, sociodemographic characteristics, clinical, and neuroimaging data were analyzed with Kruskal-Wallis test and generalized linear models (GLM).

RESULTS

The average QOLIE-31 score was 55.8 (SD ± 7.6), with 119 individuals (76.8%) scoring in the poor quality-of-life category. Generalized tonic-clonic seizures and secondarily generalized epileptic seizures were associated with a lower QOLIE-31, as well as a low level of education with a value of p = 0.05. There were no associations between QOLIE-31 scores and other variables such as sex, age, antiepileptic medication, number of parasitic cysts, and number of compromised brain regions. On multivariate analysis, a greater number of generalized epileptic seizures maintained a statistically significant association with detrimental QOLIE-31 scores.

CONCLUSION

Quality of life is affected in NCC, mainly in relation to the number of prior generalized epileptic seizures.

Patient complexity, depression, and quality of life in patients with epilepsy at an epilepsy center in Japan

Objective

The relationship between care complexity and quality of life among patients with epilepsy has not been assessed, especially in Japan. The aim of this study is to test the hypothesis that care complexity is associated with health‐related quality of life (HRQOL) and mood disturbance.

Method

This was an observational cross‐sectional study. The study included a consecutive series of 49 patients who newly visited an epilepsy center. Study participants were administered standardized quantitative measures of HRQOL, case complexity, and depression.

Results

Patient complexity predicted lower HRQL scores. Data on the social and psychological complexity domains predicted patient HRQOL findings more accurately than data from the biological domain of the case complexity scale. Seizure frequency was unrelated to HRQOL findings in this study. Additionally, depression scores were also associated with lower HRQOL.

Significance

A patient complexity assessment, including psychological and social domains, may be one of the key tools in epilepsy treatment settings. Further studies using larger random selection from patients with epilepsy are necessary to generalize the findings to patients in other epilepsy programs.

The importance of drug titration in the management of patients with epilepsy

The variable response to antiseizure medication (ASM) treatment and the numerous drug- and patient-related factors that must be considered when initiating therapy make drug titration to an optimal and tolerable dose an essential component in the pharmacologic treatment of patients with epilepsy. When initiating a new ASM, a "start low, go slow" titration approach is generally recommended and has been shown to reduce the risk of severe idiosyncratic reactions with certain medications and improve tolerability with regard to many frequently occurring central nervous system-related adverse effects (e.g., somnolence, dizziness). Many patients with epilepsy will require medication changes due to lack of efficacy or intolerability of the initial regimen. When this occurs, patients may be switched from one monotherapy to another or receive adjunctive therapy. When transitioning a patient from one ASM to another (referred to as monotherapy conversion or transitional polytherapy), there are several strategies for tapering the baseline ASM depending on the clinical scenario. Regardless of the particular strategy, the goal should be to discontinue the baseline ASM in order to prevent increased toxicity due to drug load. When adding on ASM therapy, flexible titration of the new ASM and adjustment of concomitant ASMs to achieve disease control with the lowest possible drug load (lowest numbers and lowest doses) may help improve tolerability of the add-on therapy. Communication with patients during the initiation of a new therapy may help patients adhere to the titration schedule, allowing them to reach their optimal maintenance dose.

Effects of Epidiolex® (Cannabidiol) on seizure-related emergency department visits and hospital admissions: A retrospective cohort study

AIM

The aim of this study was to evaluate the potential impact of cannabidiol (CBD) on healthcare resource utilization and determine the effect of CBD on seizure-related emergency departments (ED) and hospital admissions in patients with epilepsy.

METHODS

This single-center, retrospective longitudinal cohort study included patients ≥1 year on CBD, excluding participants in CBD clinical trials or on <6 months of CBD therapy. Demographics, antiseizure medications (ASM), ED and hospital admissions were collected from the electronic medical record. Co-primary outcomes included change in seizure-related ED and hospital admissions. Secondary outcomes included change in ASMs and total ED or hospital admissions. Co-primary outcomes were assessed using generalized linear modeling. Descriptive statistics were used to analyze all other variables.

RESULTS

In the one-hundred total patients, there was no difference in either seizure-related ED visits (0.012 vs 0.011, p = 0.85) or hospital admissions per month (0.019 vs 0.021, p = 0.7). However, given the low percentage of the total cohort (n = 100) with either a seizure-related ED visits and hospital admissions (9% and 18%, respectively), a subgroup analysis was conducted. Those with seizure-related hospital admissions prior to CBD (n = 18) had significantly less seizure-related hospital admissions after initiation of CBD (23 admissions [0.104 per month] vs 15 admissions [0.055 per month], p = 0.007).

CONCLUSION

Despite the lack of statistically significant difference in primary outcomes for the total cohort, CBD may have a potential for a clinically beneficial impact in real-world settings on those patients with prior seizure-related admissions, who are the highest utilizers of healthcare resources.

Supervised machine learning to predict reduced depression severity in people with epilepsy through epilepsy self-management intervention

OBJECTIVE

To develop a classifier that predicts reductions in depression severity in people with epilepsy after participation in an epilepsy self-management intervention.

METHODS

Ninety-three people with epilepsy from three epilepsy self-management randomized controlled trials from the Managing Epilepsy Well (MWE) Network integrated research database met the inclusion criteria. Supervised machine learning algorithms were utilized to develop prediction models for changes in self-reported depression symptom severity. Features considered by the machine learning classifiers include age, gender, race, ethnicity, education, study type, baseline quality of life, and baseline depression symptom severity. The models were trained and evaluated on their ability to predict clinically meaningful improvement (i.e., a reduction of greater than three points on the nine-item Patient Health Questionnaire (PHQ-9)) between baseline and follow-up (<=12 weeks) depression scores. Models tested were a Multilayer Perceptron (ML), Random Forest (RF), Support Vector Machine (SVM), Logistic Regression with Stochastic Gradient Descent (SGD), K-nearest Neighbors (KNN), and Gradient Boosting (GB). A separate, outside dataset of 41 people with epilepsy was used in a validation exercise to examine the top-performing model's generalizability and performance with external data.

RESULTS

All six classifiers performed better than our baseline mode classifier. Support Vector Machine had the best overall performance (average area under the curve [AUC] = 0.754, highest subpopulation AUC = 0.963). Our analysis of the SVM features revealed that higher baseline depression symptom severity, study type (i.e., intervention program goals), higher baseline quality of life, and race had the strongest influence on increasing the likelihood that a subject would experience a clinically meaningful improvement in depression scores. From the validation exercise, our top-performing SVM model performed similarly or better than the average SVM model with the outside dataset (average AUC = 0.887).

SIGNIFICANCE

We trained an SVM classifier that offers novel insight into subject-specific features that are important for predicting a clinically meaningful improvement in subjective depression scores after enrollment in a self-management program. We provide evidence for machine learning to select subjects that may benefit most from a self-management program and indicate important factors that self-management programs should collect to develop improved digital tools.

Effectiveness and safety of adjunctive cenobamate for focal seizures in adults with developmental disability treated in clinical practice

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92.9% (26/28 patients) continued cenobamate through 6 months, showing high retention.

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High responder rates/substantial focal seizure reduction occurred with cenobamate.

•

100% seizure reduction occurred in 48.2% of patients at 6 months.

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Adverse effects were often mitigated by concomitant antiseizure medication reduction.

Effectiveness and tolerability of adjunctive cenobamate for uncontrolled focal seizures in adults living with a developmental disability are not defined. Retrospective medical record review included adults ≥18 years old living with a developmental disability, either in a group home or with parents, and experiencing uncontrolled focal seizures despite stable doses of ≥1 antiseizure medication (ASM). Effectiveness was examined as percentage change in focal seizure frequency per month from the 2-month average before cenobamate to the average of months 5 and 6 while receiving cenobamate. Percentages of patients achieving responder rates in focal seizure frequency at 6 months of cenobamate treatment were examined. Adverse effects and concomitant ASM dosage adjustments were assessed. Of the 28 included patients, 26 (92.9%) continued cenobamate beyond 6 months. The responder rate of 100% seizure reduction (seizure-free) occurred in 48.2% of the patients who continued cenobamate for 6 months. Ten adverse effects were reported in 9 patients (32.1%), and 80% (8/10) were resolved by reducing concomitant ASM dosages. Two patients (7.1%) discontinued cenobamate due to adverse effects. Cenobamate resulted in substantial reduction in focal seizure frequency and was well tolerated.

Wearable Reduced-Channel EEG System for Remote Seizure Monitoring

Epitel has developed Epilog, a miniature, wireless, wearable electroencephalography (EEG) sensor. Four Epilog sensors are combined as part of Epitel's Remote EEG Monitoring platform (REMI) to create 10 channels of EEG for remote patient monitoring. REMI is designed to provide comprehensive spatial EEG recordings that can be administered by non-specialized medical personnel in any medical center. The purpose of this study was to determine how accurate epileptologists are at remotely reviewing Epilog sensor EEG in the 10-channel “REMI montage,” with and without seizure detection support software. Three board certified epileptologists reviewed the REMI montage from 20 subjects who wore four Epilog sensors for up to 5 days alongside traditional video-EEG in the EMU, 10 of whom experienced a total of 24 focal-onset electrographic seizures and 10 of whom experienced no seizures or epileptiform activity. Epileptologists randomly reviewed the same datasets with and without clinical decision support annotations from an automated seizure detection algorithm tuned to be highly sensitive. Blinded consensus review of unannotated Epilog EEG in the REMI montage detected people who were experiencing electrographic seizure activity with 90% sensitivity and 90% specificity. Consensus detection of individual focal onset seizures resulted in a mean sensitivity of 61%, precision of 80%, and false detection rate (FDR) of 0.002 false positives per hour (FP/h) of data. With algorithm seizure detection annotations, the consensus review mean sensitivity improved to 68% with a slight increase in FDR (0.005 FP/h). As seizure detection software, the automated algorithm detected people who were experiencing electrographic seizure activity with 100% sensitivity and 70% specificity, and detected individual focal onset seizures with a mean sensitivity of 90% and mean false alarm rate of 0.087 FP/h. This is the first study showing epileptologists' ability to blindly review EEG from four Epilog sensors in the REMI montage, and the results demonstrate the clinical potential to accurately identify patients experiencing electrographic seizures. Additionally, the automated algorithm shows promise as clinical decision support software to detect discrete electrographic seizures in individual records as accurately as FDA-cleared predicates.

Clinical factors associated with work disability in epilepsy: A cross-sectional study at a tertiary referral hospital

OBJECTIVE

The impact of epilepsy on work disability remains unclear. The aim of this study was to determine the percentage of patients with epilepsy who are unemployed or on temporary or permanent disability leave and to analyze associated clinical factors.

METHODS

We performed an observational cross-sectional study of consecutively recruited patients with epilepsy seen at a specialized epilepsy unit or admitted to the epilepsy monitoring unit of a tertiary referral hospital. We analyzed the percentage of patients who were actively employed, unemployed, and on temporary or permanent disability leave. The groups were compared for sociodemographic data (age, sex, marital status, and type of work), clinical data (type of epilepsy, disease duration, monthly seizure frequency, and presence of anxiety or depression), treatment-related factors, and quality of life.

RESULTS

We included 742 patients (53% male, mean age 44.3 ± 13.7 years old): 40.5% were employed, 29.2% were unemployed, 19% were on temporary disability leave, and 11.1% had a permanent work disability. Depressive symptoms and poorer quality of life were associated with unemployment (OR 2.3, p = 0.02 and OR 1.8, p = 0.01), temporary disability leave (OR 1.4, p = 0.05 and OR 1.7, p = 0.02), and permanent work disability (OR 1.9, p = 0.01 and OR 2.2, p = 0.01). Low-skilled work was also predictive of unemployment (OR 1.9, p = 0.04), temporary disability leave (OR 2.8, p = 0.03), and permanent work disability (OR 1.7, p = 0.04). A higher monthly seizure frequency was associated with permanent work disability (OR 2.01, p = 0.02).

CONCLUSION

Less than 50% of patients with epilepsy in our setting are working. Factors associated with unemployment and work disability are a higher frequency of seizures, low-skilled work, depressive symptoms, and poor quality of life.

Seizure Forecasting Using a Novel Sub-Scalp Ultra-Long Term EEG Monitoring System

Accurate identification of seizure activity, both clinical and subclinical, has important implications in the management of epilepsy. Accurate recognition of seizure activity is essential for diagnostic, management and forecasting purposes, but patient-reported seizures have been shown to be unreliable. Earlier work has revealed accurate capture of electrographic seizures and forecasting is possible with an implantable intracranial device, but less invasive electroencephalography (EEG) recording systems would be optimal. Here, we present preliminary results of seizure detection and forecasting with a minimally invasive sub-scalp device that continuously records EEG. Five participants with refractory epilepsy who experience at least two clinically identifiable seizures monthly have been implanted with sub-scalp devices (Minder®), providing two channels of data from both hemispheres of the brain. Data is continuously captured via a behind-the-ear system, which also powers the device, and transferred wirelessly to a mobile phone, from where it is accessible remotely via cloud storage. EEG recordings from the sub-scalp device were compared to data recorded from a conventional system during a 1-week ambulatory video-EEG monitoring session. Suspect epileptiform activity (EA) was detected using machine learning algorithms and reviewed by trained neurophysiologists. Seizure forecasting was demonstrated retrospectively by utilizing cycles in EA and previous seizure times. The procedures and devices were well-tolerated and no significant complications have been reported. Seizures were accurately identified on the sub-scalp system, as visually confirmed by periods of concurrent conventional scalp EEG recordings. The data acquired also allowed seizure forecasting to be successfully undertaken. The area under the receiver operating characteristic curve (AUC score) achieved (0.88), which is comparable to the best score in recent, state-of-the-art forecasting work using intracranial EEG.

Improving surgical outcome with electric source imaging and high field magnetic resonance imaging

While most patients with focal epilepsy present with clear structural abnormalities on standard, 1.5 or 3 T MRI, some patients are MRI-negative. For those, quantitative MRI techniques, such as volumetry, voxel-based morphometry, and relaxation time measurements can aid in finding the epileptogenic focus. High-field MRI, just recently approved for clinical use by the FDA, increases the resolution and, in several publications, was shown to improve the detection of focal cortical dysplasias and mild cortical malformations. For those cases without any tissue abnormality in neuroimaging, even at 7 T, scalp EEG alone is insufficient to delimitate the epileptogenic zone. They may benefit from the use of high-density EEG, in which the increased number of electrodes helps improve spatial sampling. The spatial resolution of even low-density EEG can benefit from electric source imaging techniques, which map the source of the recorded abnormal activity, such as interictal epileptiform discharges, focal slowing, and ictal rhythm. These EEG techniques help localize the irritative, functional deficit, and seizure-onset zone, to better estimate the epileptogenic zone. Combining those technologies allows several drug-resistant cases to be submitted to surgery, increasing the odds of seizure freedom and providing a must needed hope for patients with epilepsy.

The effect of dexketoprofen trometamol on WAG/Rij rats with absence epilepsy (dexketoprofen in absence epilepsy)

AIM

Epilepsy is one of the most common neurological diseases. Dexketoprofen (DEX) is a nonselective nonsteroidal anti-inflammatory drug that is used as an analgesic. The present study aimed to assess the efficiency of DEX on WAG/Rij rats by electrophysiologically and behaviorally.

MATERIAL AND METHODS

Twenty-eight male WAG/Rij rats were used. The effects of acute treatment with DEX (5, 25, and 50 mg/kg, i.p) on absence-like seizures, and related psychiatric comorbidity were assessed. The ECoG recording was taken for 180 min before and after drug injection. After drug injection and EcoG recording, anxiety-depression-like behavior was tested with the open field test for 5 min.

RESULTS

The 5 mg/kg DEX significantly reduced the number and duration of SWDs percentage (p < 0.05) between 120 and 180 min, but 25 and 50 mg/kg DEX significantly increased the number and duration of SWDs percentage between 0 and 30 min (p < 0.05), and after 30 min the increase stopped (p > 0.05). And also, the 5 mg/kg DEX decreased the number and duration of SWDs percentage (p < 0.05) for 180 min (p < 0.05), but 25 and 50 mg/kg DEX administration did not alter (p > 0.05). The 5, 25, and 50 mg/kg doses of DEX significantly increased the duration of grooming (p < 0.05) but did not change the number of squares crossed (p > 0.05).

CONCLUSION

Low dose DEX reduced absence-like seizures, but care should be taken when using high doses in absence epilepsy. Also, it may be beneficial for painful diseases accompanied by anxiety-depression.

Effects of Sodium Valproate Monotherapy on Blood Liver Enzyme Levels in Patients with Epilepsy: A Meta-Analysis

We conducted this meta-analysis to assess the effects of sodium valproate (VPA) monotherapy on blood liver enzymes in patients with epilepsy. PubMed, Web of Science, EBSCO, Cochrane Library, Wanfang, China national knowledge infrastructure databases were searched. Nine studies were included. Results showed: (1) The overall SMD for blood AST, ALT, and GGT levels of VPA monotherapy group versus control group were 0.70 (95% CI=0.31 to 1.09, Z=3.52, p=0.0004), 0.47 (95% CI=- 0.01 to 0.95, Z=1.91, p=0.06), 0.44 (95% CI=0.29 to 0.60, Z=5.55, p<0.00001), respectively. (2) In subgroup meta-analysis, increased blood AST and GGT levels were observed in epileptic minors (AST: total SMD=0.85, 95% CI=0.40 to 1.30, Z=3.69, p=0.0002; GGT: total SMD=0.46, 95% CI=0.29 to 0.63, Z=5.25, p<0.00001). Elevated blood ALT level was observed in Asian patients receiving VPA monotherapy (total SMD=0.70, 95% CI=0.51 to 0.90, Z=7.01, p<0.00001), and the early stage of VPA monotherapy (total SMD=0.93, 95% CI=0.57 to 1.29, Z=5.09, p<0.00001). Overall, our results indicated that blood AST and GGT were significantly increased in epileptic minors receiving VPA monotherapy. The elevation of blood ALT was observed in Asian patients and the early stage of VPA monotherapy. However, due to the small number of included studies, our results should be considered with caution.

Quality of life long after temporal lobe epilepsy surgery

OBJECTIVES

To identify variables independently associated with a meaningful improvement in QOL long after surgical treatment of drug-resistant MTLE-HS patients.

MATERIAL & METHODS

We prospectively evaluated 72 consecutive MTLE-HS surgically treated patients and analyzed pre and post-surgical variables independently associated with a meaningful improvement in QOL evaluated by the Quality of Life in Epilepsy-31 (QOLIE-31) overall score, and its domain scores determined at follow-up after 36 to 131 months (mean 93 months) after surgery.

RESULTS

The mean overall QOLIE-31 score and its subdomain scores improved significantly after surgery (p < 0.01), and 55 patients (76.4%) had a meaningful QOL improvement. Being seizure-free (Engel IA) after surgery showed a non-significant association (OR 2.63, CI 95% 0.53 to 13.05, p = 0.23) and lower depressive symptoms a significant association (OR 4.15, CI 95% 1.19 to 14.53, p = 0.03) with meaningful improvement of QOL.

CONCLUSIONS

Patients with MTLE-HS who underwent epilepsy surgery show a sustained, meaningful improvement in their QOL. Pre-surgical variables do not predict long-term QOL improvement after surgery. Lower levels of depressive symptoms at postoperative evaluation are associated with meaningful QOL improvement.

Electrographic seizure monitoring with a novel, wireless, single-channel EEG sensor

Objective

Recording seizures using personal seizure diaries can be challenging during everyday life and many seizures are missed or mis-reported. People living with epilepsy could benefit by having a more accurate and objective wearable EEG system for counting seizures that can be used outside of the hospital. The objective of this study was to (1) determine which seizure types can be electrographically recorded from the scalp below the hairline, (2) determine epileptologists' ability to identify electrographic seizures from single-channels extracted from full-montage wired-EEG, and (3) determine epileptologists' ability to identify electrographic seizures from Epilog, a wireless single-channel EEG sensor.

Methods

Epilog sensors were worn concurrently during epilepsy monitoring unit (EMU) monitoring. During standard-of-care review, epileptologists were asked if the electrographic portion of the seizure was visible on single channels of wired electrodes at locations proximal to Epilog sensors, and if focal-onset, which electrode was closest to the focus. From these locations, single channels of EEG extracted from wired full-montage EEG and the proximal Epilog sensor were presented to 3 blinded epileptologists along with markers for when known seizures occurred (taken from the standard-of-care review). Control segments at inter-ictal times were included as control. The epileptologists were asked whether a seizure event was visible in the single channel EEG record at or near the marker.

Results

A total of 75 seizures were recorded from 22 of 40 adults that wore Epilog during their visit to the EMU. Epileptologists were able to visualize known seizure activity on at least one of the wired electrodes proximal to Epilog sensors for all seizure events. Epileptologists accurately identified seizures in 71% of Epilog recordings and 84% of single-channel wired recordings and were 92% accurate identifying seizures with Epilog when those seizures ended in a clinical convulsion compared to those that did not (>55%).

Conclusions

Epileptologists are able to visualize seizure activity on single-channels of EEG at locations where Epilog sensors are easily placed on the scalp below hairline. Manual review of seizure annotations can be done quickly and accurately (>70% TP and >98% PPV) on single-channel EEG data. Reviewing single-channel EEG is more accurate than what has been reported in the literature on self-reporting seizures in seizure diaries, the current standard of care for seizure counting outside of the EMU.

Significance

Wearable EEG will be important for seizure monitoring outside of the hospital. Epileptologists can accurately identify seizures in single-channel EEG, better than patient self-reporting in diaries based on the literature. Automated or semi-automated seizure detection on single channels of EEG could be used in the future to objectively count seizures to complement the standard of care outside of the EMU without the overt burden upon epileptologist review.

Evaluation of two anti-seizure medication strategies in refractory epilepsy patients from a tertiary center with complementary insights from data visualization

OBJECTIVE

To evaluate the healthcare resources in a tertiary center related to exclusive use of non-enzyme inducing anti-seizure medications relative to concomitant use of enzyme-inducing anti-seizure medications in patients with refractory epilepsy.

METHODS

In this retrospective case-time-control study, we compared the effects of two anti-seizure medication strategies: exclusively non-inducing anti-seizure medications (NIND) or a combination of NIND and inducing anti-seizure medications (IND+). The primary outcome parameter was the number of consultations with relevant healthcare professionals in our tertiary center, assessed with a negative binomial regression model, adjusting for several covariates like blood drug level and time interval (TI). Results from statistical models were visualized to explore the contribution of all covariates on the outcome in the total population and in subgroups.

RESULTS

From the 21538 patients with refractory epilepsy referred to our center 1648 patients met the inclusion criteria. The regression model showed that the IND + strategy was significantly associated with fewer consultations compared to the NIND strategy (p < 0.001), reflected in an incidence risk ratio (IRR) of 0.844 (0.799-0.890). Visualization of subgroups, defined by anti-seizure medications strategy, revealed patterns in contribution of blood drug level measurements on the outcome. Although sex was not included as a covariate in the regression model, as it was eliminated by the backward-elimination approach, visualization of this subgroup showed differences in effects of blood drug level and TI.

CONCLUSION

For patients with refractory epilepsy in our tertiary center, treatment following the IND + strategy is associated with fewer consultations with healthcare professionals compared to the NIND strategy. Comprehensive visualization of the results facilitated the exploration of effects of covariates across subgroups.

Prevalence of Medically Resistant Epilepsy in Saudi Arabia

OBJECTIVES

The objective of this study was to evaluate the prevalence of medically resistant epilepsy (MRE) in our hospital and to compare the prevalence with that in other populations.

METHODS

We retrospectively analyzed the data of patients who visited the epilepsy clinics at King Fahd University Hospital, Al-Khobar, Saudi Arabia between January 2017 and December 2018. This study included patients aged ≥14 years who had at least 2 unprovoked seizures 24 h apart. Patients who had provoked seizure(s), paroxysmal events, or syncope or had incomplete medical records were excluded. The definition and classification of the International League Against Epilepsy were used. Moreover, we searched the En-glish literature using PubMed and Google Scholar to compare the prevalence of MRE between our population and other populations.

RESULTS

In total, 1,151 patients were screened, and 751 patients were included in the final analysis. Of the 751 patients, 229 (male: 56.3%, female: 43.7%; mean age: 32.07 years, and standard deviation, 12.2 years) had MRE, with a cumulative prevalence of 30%. The etiology was as follows: unknown, 63.3% (n = 145); structural, 31.9% (n = 73); genetic, 3.1% (n = 7); and infectious, 1.7% (n = 4). None of the patients had metabolic or immune-related etiologies.

CONCLUSION

The prevalence of MRE in our population (30%) is close to that in other populations (30-36.5%). Early identification of such patients is crucial to improve their management.

Behavioral adverse events with brivaracetam, levetiracetam, perampanel, and topiramate: A systematic review

PURPOSE

To understand the currently available post-marketing real-world evidence of the incidences of and discontinuations due to the BAEs of irritability, anger, and aggression in people with epilepsy (PWE) treated with the anti-seizure medications (ASMs) brivaracetam (BRV), levetiracetam (LEV), perampanel (PER), and topiramate (TPM), as well as behavioral adverse events (BAEs) in PWE switching from LEV to BRV.

METHODS

A systematic review of published literature using the Cochrane Library, PubMed/MEDLINE, and Embase was performed to identify retrospective and prospective observational studies reporting the incidence of irritability, anger, or aggression with BRV, LEV, PER, or TPM in PWE. The incidences of these BAEs and the rates of discontinuation due to each were categorized by ASM, and where possible, weighted means were calculated but not statistically assessed. Behavioral and psychiatric adverse events in PWE switching from LEV to BRV were summarized descriptively.

RESULTS

A total of 1500 records were identified in the searches. Of these, 44 published articles reporting 42 studies met the study criteria and were included in the data synthesis, 7 studies were identified in the clinical trial database, and 5 studies included PWE switching from LEV to BRV. Studies included a variety of methods, study populations, and definitions of BAEs. While a wide range of results was reported across studies, weighted mean incidences were 5.6% for BRV, 9.9% for LEV, 12.3% for PER, and 3.1% for TPM for irritability; 3.3%* for BRV, 2.5% for LEV, 2.0% for PER, and 0.2%* for TPM for anger; and 2.5% for BRV, 2.6% for LEV, 4.4% for PER, and 0.5%* for TPM for aggression. Weighted mean discontinuation rates were 0.8%* for BRV, 3.4% for LEV, 3.0% for PER, and 2.2% for TPM for irritability and 0.8%* for BRV, 2.4% for LEV, 9.2% for PER, and 1.2%* for TPM for aggression. There were no discontinuations for anger. Switching from LEV to BRV led to improvement in BAEs in 33.3% to 83.0% of patients (weighted mean, 66.6%). *Denotes only 1 study.

CONCLUSIONS

This systematic review characterizes the incidences of irritability, anger, and aggression with BRV, LEV, PER, and TPM, and it provides robust real-world evidence demonstrating that switching from LEV to BRV may improve BAEs. While additional data remain valuable due to differences in methodology (which make comparisons difficult), these results improve understanding of the real-world incidences of discontinuations due to these BAEs in clinical practice and can aid in discussions and treatment decision-making with PWE.