Lacosamide: what can be expected from the next new antiepileptic drug?

Seizures in children treated for a primary brain tumor: risk factors, evaluation and management

ABSTRACT 

Seizures may be a presenting symptom of a brain tumor in childhood or can occur as a complication of treatment or subsequent effect occurring years after completion of therapy. Seizures create a number of therapeutic challenges and represent a significant comorbidity that results in decreased quality of life. Treatment options may be limited by interactions with chemotherapy and/or increased susceptibility to side effects. Moreover, seizures in this patient population may be less responsive to the traditional therapies typically effective for nontumor related epilepsy. While the pathophysiology of tumor-related epilepsy remains unclear, advances are being made in our understanding of the possible mechanisms involved. Newer anticonvulsants and improved diagnostic tools with refined surgical techniques show promise for future treatment approaches.

Newer anticonvulsant medications in pediatric neurology

OPINION STATEMENT

Antiepileptic drugs (AEDs) are the mainstay of treatment for recurrent seizures. Uncontrolled seizures may cause medical, developmental, and psychological disturbances. The medical practitioner should thus strive to eliminate or minimize seizures. Treatment advances in epilepsy include 1) identification of the basic mechanisms of epilepsy and action of AEDs, 2) the introduction of new AEDs, and 3) the use of neurostimulation, including vagus nerve stimulation. Treatment with AEDs involves balancing each AED's efficacy against its side effects. In some patients, effective AEDs must be discontinued because of intolerable side effects. Although all AEDs have a proven efficacy, the choice of AEDs should be based on better efficacy for individual seizure types or epilepsy syndromes. Side effects also differ from drug to drug and must be taken into account. This article focuses on studies and expert opinion consensus to guide the choice of AEDs.

Experience with lacosamide in a series of children with drug-resistant focal epilepsy

We report our pediatric experience with lacosamide, a new antiepileptic drug, approved by the US Food and Drug Administration as adjunctive therapy in focal epilepsy in patients more than 17 years old. We retrospectively reviewed charts for lacosamide use and seizure frequency outcome in patients with focal epilepsy (Wilcoxon signed rank test). Sixteen patients (7 boys) were identified (median dose 275 mg daily, 4.7 mg/kg daily; mean age 14.9 years, range 8-21 years). Patients were receiving a median of 2 antiepileptic drugs (interquartile range [IQR] 1.7-3) in addition to having undergone previous epilepsy surgery (n=3), vagus nerve stimulation (n=9), and ketogenic diet (n=3). Causes included structural (encephalomalacia and diffuse encephalitis, 1 each; stroke in 2) and genetic abnormalities (Aarskog and Rett syndromes, 1 each) or cause not known (n=10). Median seizure frequency at baseline was 57 per month (IQR 7-75), and after a median follow-up of 4 months (range 1-13 months) of receiving lacosamide, it was 12.5 per month (IQR 3-75), (P<0.01). Six patients (37.5%; 3 seizure free) were classified as having disease that responded to therapy (≥50% reduction seizure frequency) and 10 as having disease that did not respond to therapy (<50% in 3; increase in 1; unchanged in 6). Adverse events (tics, behavioral disturbance, seizure worsening, and depression with suicidal ideation in 1 patient each) prompted lacosamide discontinuation in 4/16 (25%). This retrospective study of 16 children with drug-resistant focal epilepsy demonstrated good response to adjunctive lacosamide therapy (median seizure reduction of 39.6%; 37.5% with ≥50% seizure reduction) without severe adverse events.

Management of epilepsy in drug-resistant patients

Epilepsy affects > 2 million people in the United States, making it one of the most common neurobiological conditions. Typically, epilepsy is treated with one of several available antiepileptic drugs and patients are able to experience freedom from seizures with minimal side effects. However, there are some patients who do not respond to treatment and require the use of multiple drug combinations or surgical intervention. Although there are few studies supporting its use, multi-drug regimens have been known to be helpful for patients, although clinicians should monitor patients for adverse side effects. Vagus nerve stimulation is the only US Food and Drug Administration-approved surgical neurostimulation therapy for epilepsy, and patients' conditions often progress for many years before epilepsy surgery options are considered. Lastly, due to the chronic nature of epilepsy, clinicians should be aware of the presence of comorbid psychiatric conditions as well. This supplement is Part One in the "Case in Point: Evidence-Based Insights for Epilepsy Management" series. In this Expert Review Supplement, Andrew J. Cole, MD, FRCPC, outlines a case of a patient with drug resistant epilepsy, and Brien J. Smith, MD, outlines the best practices for the case patient including discussion on defining drug resistance in patients as well as the benefits and risks of available and emerging drug and surgical treatments.