1
|
Li X, Yue W. Comparative analysis of dexmedetomidine, midazolam, and propofol impact on epilepsy-related mortality in the ICU: insights from the MIMIC-IV database. BMC Neurol 2024; 24:193. [PMID: 38849716 PMCID: PMC11157909 DOI: 10.1186/s12883-024-03693-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 05/27/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND Dexmedetomidine (Dex), midazolam, and propofol are three distinct sedatives characterized by varying pharmacological properties. Previous literature has indicated the positive impact of each of these sedatives on ICU patients. However, there is a scarcity of clinical evidence comparing the efficacy of Dex, midazolam, and propofol in reducing mortality among people with epilepsy (PWE). This study aimed to assess the impact of Dex, midazolam, and propofol on the survival of PWE. METHODS The data were retrospectively retrieved from the Medical Information Mart for Intensive Care (MIMIC)-IV database (version 2.0). PWE were categorized into Dex, midazolam, and propofol groups based on the intravenously administered sedatives. PWE without standard drug therapy were included in the control group. Comparative analyses were performed on the data among the groups. RESULTS The Dex group exhibited a significantly lower proportion of in-hospital deaths and a markedly higher in-hospital survival time compared to the midazolam and propofol groups (p < 0.01) after propensity score matching. Kaplan-Meier curves demonstrated a significant improvement in survival rates for the Dex group compared to the control group (p = 0.025). Analysis of Variance (ANOVA) revealed no significant differences in survival rates among the Dex, midazolam, and propofol groups (F = 1.949, p = 0.143). The nomogram indicated that compared to midazolam and propofol groups, Dex was more effective in improving the survival rate of PWE. CONCLUSION Dex might improve the survival rate of PWE in the ICU compared to no standard drug intervention. However, Dex did not exhibit superiority in improving survival rates compared to midazolam and propofol.
Collapse
Affiliation(s)
- Xun Li
- Clinical College of Neurology, Neurosurgery, and Neurorehabilitation, Tianjin Medical University, Tianjin, China
- Department of Neurology, Tianjin Huanhu Hospital, No.6 Ji Zhao Road, Jinnan District, Tianjin, 300060, China
| | - Wei Yue
- Clinical College of Neurology, Neurosurgery, and Neurorehabilitation, Tianjin Medical University, Tianjin, China.
- Department of Neurology, Tianjin Huanhu Hospital, No.6 Ji Zhao Road, Jinnan District, Tianjin, 300060, China.
| |
Collapse
|
2
|
Gonçalves-Sánchez J, Ramírez-Santos T, López DE, Gonçalves-Estella JM, Sancho C. Assessing the Effectiveness of Eslicarbazepine Acetate in Reducing Audiogenic Reflex Seizures in the GASH/Sal Model of Epilepsy. Biomedicines 2024; 12:1121. [PMID: 38791083 PMCID: PMC11117828 DOI: 10.3390/biomedicines12051121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 05/03/2024] [Accepted: 05/16/2024] [Indexed: 05/26/2024] Open
Abstract
Eslicarbazepine acetate (ESL) is a third-generation antiepileptic drug indicated as monotherapy for adults with newly diagnosed epilepsy and as adjunctive therapy for the treatment of partial seizures. Our aim was to assess the effectiveness and safety of both acute and repeated ESL administration against reflex audiogenic seizures, as shown by the Genetic Audiogenic Seizures Hamster from Salamanca (GASH/Sal). Animals were subject to the intraperitoneal administration of ESL, applying doses of 100, 150 and 200 mg/kg for the acute study, whereas a daily dose of 100 mg/kg was selected for the subchronic study, which lasted 14 days. In both studies, the anticonvulsant effect of the therapy was evaluated using neuroethological methods. To assess the safety of the treatment, behavioral tests were performed, hematological and biochemical liver profiles were obtained, and body weight was monitored. In addition, the ESL levels in blood were measured after the acute administration of a 200 mg/kg dose. Treatment with ESL caused a reduction in seizure severity. No statistically significant differences were detected between the selected doses or between the acute or repeated administration of the drug. To summarize, the intraperitoneal administration of ESL is safe and shows an anticonvulsant effect in the GASH/Sal.
Collapse
Affiliation(s)
- Jaime Gonçalves-Sánchez
- Department of Cell Biology and Pathology, School of Medicine, University of Salamanca, 37007 Salamanca, Spain
- Institute for Biomedical Research of Salamanca (IBSAL), 37007 Salamanca, Spain
- Institute of Neuroscience of Castilla y León, 37007 Salamanca, Spain
| | | | - Dolores E. López
- Department of Cell Biology and Pathology, School of Medicine, University of Salamanca, 37007 Salamanca, Spain
- Institute for Biomedical Research of Salamanca (IBSAL), 37007 Salamanca, Spain
- Institute of Neuroscience of Castilla y León, 37007 Salamanca, Spain
| | - Jesús M. Gonçalves-Estella
- Institute for Biomedical Research of Salamanca (IBSAL), 37007 Salamanca, Spain
- Department of Surgery, School of Medicine, University of Salamanca, 37007 Salamanca, Spain
| | - Consuelo Sancho
- Institute for Biomedical Research of Salamanca (IBSAL), 37007 Salamanca, Spain
- Institute of Neuroscience of Castilla y León, 37007 Salamanca, Spain
- Department of Physiology and Pharmacology, School of Medicine, University of Salamanca, 37007 Salamanca, Spain
| |
Collapse
|
3
|
Basheikh MA. Assessing the Incidence Rate of Neuropsychiatric Adverse Effects in Older Adults Following Levetiracetam Initiation: A Retrospective Study. Int J Gen Med 2024; 17:2011-2020. [PMID: 38736674 PMCID: PMC11088830 DOI: 10.2147/ijgm.s458803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 05/03/2024] [Indexed: 05/14/2024] Open
Abstract
Background Levetiracetam (LEV) is commonly prescribed for epilepsy management. However, neuropsychiatric disorders (NPDs) are concerning adverse effects that may result in medication discontinuation. This study aims to examine the incidence and factors influencing LEV associated NPDs in adult patients aged 50 years and above. Methods A retrospective analysis was conducted on patients aged 50 years and above prescribed LEV between 2010 and 2020, with at least one follow-up appointment six months post-treatment initiation. The incidence of new-onset or aggravated NPDs and variables potentially influencing this risk were examined. Independent t-test, chi-squared, and Fisher's exact test were used, in addition to univariate and multivariate logistic regression. Results The study included 100 patients with a mean age at LEV start of 63.31 years (SD = 16.48). Neuropsychiatric symptoms were observed in 6 (6.0%) patients. Factors associated with new-onset NPDs were younger age at epilepsy diagnosis (p=0.005), younger age at LEV start (p=0.004), and concurrent use of Carbamazepine/Oxcarbazepine (p=0.004). On multivariate analysis, only the association with Carbamazepine/Oxcarbazepine remained significant (OR 14.62, 95% CI 1.86-114.70, p=0.011). Conclusion The findings indicate that the incidence of NPDs in elderly patients is relatively low (6%). Further research with larger samples is needed in comparison with a younger sample as a control group to confirm these findings.
Collapse
Affiliation(s)
- Mazen A Basheikh
- Department of Internal Medicine, Faculty of Medicine, University of Jeddah, Jeddah, Kingdom of Saudi Arabia
- Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
| |
Collapse
|
4
|
Heger K, Kjeldstadli K, Ring N, Aaberg KM, Kjeldsen SF, Burns ML, Johannessen SI, Johannessen Landmark C. Pharmacokinetic Variability of Sulthiame: The Impact of Age, Drug-Drug Interactions, and Biochemical Markers of Toxicity in Patients with Epilepsy. Ther Drug Monit 2024; 46:237-245. [PMID: 38158595 DOI: 10.1097/ftd.0000000000001146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 07/25/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE Sulthiame is an antiseizure medication increasingly used for epilepsy. The aim of this study was to investigate the pharmacokinetic variability of sulthiame in children and adults with epilepsy with respect to age, comedication, dose, serum concentration, and biochemical markers of toxicity in a clinical setting. METHOD Retrospective quantitative data from the therapeutic drug monitoring (TDM) database at the Section for Clinical Pharmacology, the National Center for Epilepsy, Norway (2015-2021), were used. RESULTS TDM data from 326 patients (127 female/199 male) were included [mean age, 11.4 (range 2-44) years; mean weight, 41 (range 14-109) kg]. Interindividual pharmacokinetic variability in the concentration/(dose/body weight) (C/(D/kg)) ratio was 16-fold; intraindividual variability was up to 8-fold (coefficient of variation = 10%-78%). Young children (younger than 6 years) had a significantly lower C/(D/kg) ratio than older age groups ( P < 0.05). Various comedications did not significantly affect the C/(D/kg) ratio, possibly owing to the small sample size. However, CYP2C19-mediated inhibition by sulthiame was indicated because patients using clobazam and sulthiame (n = 28) had a 3.5-fold higher N-desmethylclobazam C/(D/kg) ratio than those using neutral comedication (n = 45; P < 0.001). Patients with pH values below the adjusted normal range (7.32-7.42; n = 15) had a 33% higher sulthiame concentration than those with normal pH values (n = 22; P < 0.05). Blood gas measurements, especially pH, may serve as markers of toxicity and can be used in combination with clinical data when toxicity is suspected. CONCLUSIONS This study revealed the extensive intraindividual and interindividual pharmacokinetic variability of sulthiame, with age as a contributing factor. Sulthiame has clinically relevant interactions with clobazam. The use of TDM and pH as a biochemical marker may contribute to individualized and safe sulthiame treatment.
Collapse
Affiliation(s)
- Katrine Heger
- Department of Pharmacy, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Kari Kjeldstadli
- Section for Clinical Pharmacology, Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Nelly Ring
- Section for Clinical Pharmacology, Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Kari Modalsli Aaberg
- The National Center for Epilepsy, Sandvika, Member of the ERN EpiCare, Oslo University Hospital, Oslo, Norway; and
| | - Signe Flood Kjeldsen
- Section for Clinical Pharmacology, The National Center for Epilepsy, Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Margrete Larsen Burns
- Section for Clinical Pharmacology, The National Center for Epilepsy, Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Svein I Johannessen
- The National Center for Epilepsy, Sandvika, Member of the ERN EpiCare, Oslo University Hospital, Oslo, Norway; and
- Section for Clinical Pharmacology, The National Center for Epilepsy, Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Cecilie Johannessen Landmark
- Department of Pharmacy, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
- The National Center for Epilepsy, Sandvika, Member of the ERN EpiCare, Oslo University Hospital, Oslo, Norway; and
- Section for Clinical Pharmacology, The National Center for Epilepsy, Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
5
|
Gidal BE, Resnick T, Smith MC, Wheless JW. Zonisamide: A Comprehensive, Updated Review for the Clinician. Neurol Clin Pract 2024; 14:e200210. [PMID: 38170117 PMCID: PMC10759004 DOI: 10.1212/cpj.0000000000200210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/15/2023] [Indexed: 01/05/2024]
Abstract
Purpose of Review Zonisamide (ZNS) was first approved in the United States in 2000 for the adjunctive treatment of patients aged 16 years or older with partial (focal) seizures. Although ZNS has been proven to treat multiple seizure types, it has been largely underutilized in US clinical practice. Recent Findings Published literature demonstrated that antiseizure medications (ASMs) acting on Na+ and Ca2+ channels may add beneficial effects in many seizure types by reducing seizure frequency and leading to overall improvements. In addition, effects of ZNS may lead to clinical improvements in Parkinson disease, alcohol and sleep disorders, pain, and migraine. ZNS is available in multiple formulations and is a safe and effective, broad spectrum ASM. Summary The purpose of this review was to provide an update to what is known about the efficacy of ZNS and where it shows benefits in the treatment of patients with epilepsy and other CNS disorders through its many unique mechanisms of action.
Collapse
Affiliation(s)
- Barry E Gidal
- Pharmacy Practice & Translational Research (BEG), University of Wisconsin-Madison; Department of Neurology (TR), Nicklaus Children Hospital; Department of Neurology, Florida International University, Miami, FL; Department of Neurological Sciences (MCS), Rush Medical College; Rush University Medical Center, Chicago, IL; and Pediatric Neurology (JWW), University of Tennessee Health Science Center; Neuroscience Institute & Le Bonheur Comprehensive Epilepsy Program, Le Bonheur Children's Hospital, Memphis, TN
| | - Trevor Resnick
- Pharmacy Practice & Translational Research (BEG), University of Wisconsin-Madison; Department of Neurology (TR), Nicklaus Children Hospital; Department of Neurology, Florida International University, Miami, FL; Department of Neurological Sciences (MCS), Rush Medical College; Rush University Medical Center, Chicago, IL; and Pediatric Neurology (JWW), University of Tennessee Health Science Center; Neuroscience Institute & Le Bonheur Comprehensive Epilepsy Program, Le Bonheur Children's Hospital, Memphis, TN
| | - Michael C Smith
- Pharmacy Practice & Translational Research (BEG), University of Wisconsin-Madison; Department of Neurology (TR), Nicklaus Children Hospital; Department of Neurology, Florida International University, Miami, FL; Department of Neurological Sciences (MCS), Rush Medical College; Rush University Medical Center, Chicago, IL; and Pediatric Neurology (JWW), University of Tennessee Health Science Center; Neuroscience Institute & Le Bonheur Comprehensive Epilepsy Program, Le Bonheur Children's Hospital, Memphis, TN
| | - James W Wheless
- Pharmacy Practice & Translational Research (BEG), University of Wisconsin-Madison; Department of Neurology (TR), Nicklaus Children Hospital; Department of Neurology, Florida International University, Miami, FL; Department of Neurological Sciences (MCS), Rush Medical College; Rush University Medical Center, Chicago, IL; and Pediatric Neurology (JWW), University of Tennessee Health Science Center; Neuroscience Institute & Le Bonheur Comprehensive Epilepsy Program, Le Bonheur Children's Hospital, Memphis, TN
| |
Collapse
|
6
|
Li SP, Lin LC, Yang RC, Ouyang CS, Chiu YH, Wu MH, Tu YF, Chang TM, Wu RC. Predicting the therapeutic response to valproic acid in childhood absence epilepsy through electroencephalogram analysis using machine learning. Epilepsy Behav 2024; 151:109647. [PMID: 38232558 DOI: 10.1016/j.yebeh.2024.109647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/30/2023] [Accepted: 01/10/2024] [Indexed: 01/19/2024]
Abstract
Childhood absence epilepsy (CAE) is a common type of idiopathic generalized epilepsy, manifesting as daily multiple absence seizures. Although seizures in most patients can be adequately controlled with first-line antiseizure medication (ASM), approximately 25 % of patients respond poorly to first-line ASM. In addition, an accurate method for predicting first-line medication responsiveness is lacking. We used the quantitative electroencephalogram (QEEG) features of patients with CAE along with machine learning to predict the therapeutic effects of valproic acid in this population. We enrolled 25 patients with CAE from multiple medical centers. Twelve patients who required additional medication for seizure control or who were shifted to another ASM and 13 patients who achieved seizure freedom with valproic acid within 6 months served as the nonresponder and responder groups. Using machine learning, we analyzed the interictal background EEG data without epileptiform discharge before ASM. The following features were analyzed: EEG frequency bands, Hjorth parameters, detrended fluctuation analysis, Higuchi fractal dimension, Lempel-Ziv complexity (LZC), Petrosian fractal dimension, and sample entropy (SE). We applied leave-one-out cross-validation with support vector machine, K-nearest neighbor (KNN), random forest, decision tree, Ada boost, and extreme gradient boosting, and we tested the performance of these models. The responders had significantly higher alpha band power and lower delta band power than the nonresponders. The Hjorth mobility, LZC, and SE values in the temporal, parietal, and occipital lobes were higher in the responders than in the nonresponders. Hjorth complexity was higher in the nonresponders than in the responders in almost all the brain regions, except for the leads FP1 and FP2. Using KNN classification with theta band power in the temporal lobe yielded optimal performance, with sensitivity of 92.31 %, specificity of 76.92 %, accuracy of 84.62 %, and area under the curve of 88.46 %.We used various EEG features along with machine learning to accurately predict whether patients with CAE would respond to valproic acid. Our method could provide valuable assistance for pediatric neurologists in selecting suitable ASM.
Collapse
Affiliation(s)
- Sheng-Ping Li
- Division of Pediatric Neurology, Kaohsiung Medical University Chung-Ho Memorial Hospital, Taiwan
| | - Lung-Chang Lin
- Division of Pediatric Neurology, Kaohsiung Medical University Chung-Ho Memorial Hospital, Taiwan.
| | - Rei-Cheng Yang
- Division of Pediatric Neurology, Kaohsiung Medical University Chung-Ho Memorial Hospital, Taiwan
| | - Chen-Sen Ouyang
- Department of Information Management, National Kaohsiung University of Science and Technology, Taiwan
| | - Yi-Hung Chiu
- Department of Information Engineering, I-Shou University, Taiwan
| | - Mu-Han Wu
- Department of Neurology, Tainan Hospital, Ministry of Health and Welfare, Taiwan
| | - Yi-Fang Tu
- National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Tung-Ming Chang
- Department of Pediatric Neurology, Changhua Christian Children's Hospital, Changhua, Taiwan
| | - Rong-Ching Wu
- Department of Electrical Engineering, I-Shou University, Taiwan
| |
Collapse
|
7
|
Siddiqui F, Soomro BA, Badshah M, Rehman EU, Numan A, Ikram A, Khan MWA, Ali S, Hashim H, Salam JU, Akram A, Irfan Hashmat M, Iqbal S, Zeeshan Javed M, Iqbal SZ, Maqsood A, Khan A, Maheshwary N, Khan MA. Efficacy and Safety of Brivaracetam in Persons With Epilepsy in a Real-World Setting: A Prospective, Non-Interventional Study. Cureus 2023; 15:e50313. [PMID: 38205459 PMCID: PMC10777439 DOI: 10.7759/cureus.50313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND AND AIM Epilepsy stands out as one of the most prevalent neurological conditions. Brivaracetam (BRV) is a noteworthy antiseizure medication (ASM) distinguished by its pronounced and selective interaction with the synaptic vesicle protein 2A (SV2A) within the brain. Prior investigations, including regulatory trials, post-marketing assessments, and comparative meta-analyses, have consistently underscored BRV's equivalency in efficacy and superior tolerability when pitted against other antiseizure drugs. This study aimed to evaluate the effectiveness, safety, and acceptability of BRV in treating epileptic patients in the Pakistani population. METHODS This prospective observational study, conducted in Pakistan from February to December 2022, employed a non-probability consecutive sampling technique. This study included 368 adult patients diagnosed with epilepsy, with a focus on those aged 18 and above experiencing focal seizures. Demographic data, clinical history, seizure types, and epilepsy profiles were recorded. Patients were administered BRV (Brivera; manufactured by Helix Pharma Pvt Ltd., Sindh, Pakistan) monotherapy therapy under physician guidance and followed up for three months. The study assessed changes in seizure frequency, side effects, and drug resistance at baseline, 14th day, and 90th day. Safety aspects were monitored, including documenting any adverse effects associated with BRV therapy. RESULTS A total of 368 epileptic patients were included in this study, of which 287 (61.3%) were males and 181 (38.7%) were females. The mean age was 32.91±17.11 years. The mean number of seizures at the baseline visit was 5.74±6.21, at 14 days was 2.89±3.84 and at 90 days was 1.73±5.01 (p<0.001). Overall, a more than 50% reduction in seizure episodes was achieved in 178 (56.3%) patients at day 90, and less than 50% reduction in seizure episodes was achieved by 95 (26.8%) patients on Day 14, with a highly significant association between them (p<0.001). Among 316 patients, only 41 (4.4%) of all BRV-treated patients experienced adverse events; Of these 41 patients, 17 (41.7%) reported dizziness and 14(34.2%) reported behavioral issues. CONCLUSIONS Epileptic patients receiving BRV demonstrated a substantial reduction of greater than 50% seizure episodes at the end of follow-up visits. Moreover, BRV exhibited fewer adverse effects in individuals with epilepsy.
Collapse
Affiliation(s)
- Fowzia Siddiqui
- Neurology, The Aga Khan University Hospital (AKUH), Karachi, PAK
| | | | - Mazhar Badshah
- Neurology, Pakistan Institute of Medical Sciences, Islamabad, PAK
| | - Ehsan U Rehman
- Neurology, Akhtar Saeed Medical and Dental College, Islamabad, PAK
| | - Ahsan Numan
- Neurology, Mayo Hospital, King Edward Medical University, Lahore, PAK
| | - Amer Ikram
- Neurology, Doctors Hospital Lahore, Lahore, PAK
| | | | - Sajjad Ali
- Neurology, Dar ul Shifa Hospital Sialkot, Sialkot, PAK
| | | | - Jawwad-Us Salam
- Medicine/Neurology, Dow International Medical College, Dow University of Health Sciences, Karachi, PAK
| | | | | | - Shahid Iqbal
- Neurology, Rehman Medical Institute, Peshawar, PAK
| | | | - S Zafar Iqbal
- Neurology, Tahsil Head Quarter (TQH) Hospital Sadiqabad, Sadiqabad, PAK
| | - Atif Maqsood
- Neurology, Aziz Fatima Hospital, Faisalabad, PAK
| | | | | | | |
Collapse
|
8
|
Sánchez Fernández I, Gaínza-Lein M, Amengual-Gual M, Barcia Aguilar C, Romeu A, Torres A, Jonas R, Douglass LM. Evolution of antiseizure medication use and cost in the United States of America 2006-2021. Seizure 2023; 112:128-138. [PMID: 37832279 DOI: 10.1016/j.seizure.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/08/2023] [Accepted: 10/09/2023] [Indexed: 10/15/2023] Open
Abstract
OBJECTIVE To describe the evolution in use and cost of antiseizure medications (ASM) in the United States of America (USA). METHODS Retrospective descriptive study using the IBM MarketScan Commercial Database (data of privately-insured patients) for the years 2006 to 2021. We identified patients with epilepsy who were on ASM. We adjusted cost for inflation with the Gross Domestic Product Implicit Price Deflator. RESULTS We evaluated 347,158 patients (46.9 % males; median (p25-p75) age: 33 (17-49) years; 28 % with pediatric-onset epilepsy and 72 % with adult-onset epilepsy) with a total of 1,385,382 person-years and 588,285,065 ASM prescription days. The most commonly prescribed (as percentage of prescription days) ASMs in 2006 were valproate (18 %) and lamotrigine (17 %) in pediatric-onset epilepsy and phenytoin (21 %) and carbamazepine (17 %) in adult-onset epilepsy, but starting in the 2010s, levetiracetam and lamotrigine became the most commonly prescribed ASMs in both pediatric-onset (in 2021, levetiracetam 25 %, lamotrigine 16 %) and adult-onset (in 2021, levetiracetam 27 %, lamotrigine 20 %) epilepsy. The proportion of generic ASM use increased 3.6-fold: from 23 % of prescription days in 2006 to 83 % of prescription days in 2021. The median (p25-p75) average wholesale price (AWP) per person-year increased by 102 % from $2,684 ($990-$5,509) in 2006 to $5,417 ($2,858-$12,310) in 2021. The increases were greater in absolute terms for brand-name ASMs by 419 %: $3,109 ($1,564-$5,068 in 2006 and $16,149 ($12,950-$23,377) in 2021 than for generic ASMs by 462 %: $699 ($457-$1,678) in 2006 and $3,931 ($2,618-$6,081) in 2021. The costs directly borne by the patient (copay, coinsurance, deductibles, and pharmacy processing fees) increased by 69 % for brand-name ASMs from $393 ($246-$570) in 2006 to $665 ($335-$1,308) in 2021, but decreased by 37 % for generic ASMs from $147 ($98-$213) in 2006 to $92 ($51-$141) in 2021. CONCLUSIONS The median cost of ASMs per person-year approximately doubled from 2006 to 2021. The increase in use of generic ASMs probably helped buffer the growing costs of ASMs. However, generic ASMs already represent 83 % of prescription days in 2021, with limited room to further contain costs by just increasing the proportion of generics.
Collapse
Affiliation(s)
- Iván Sánchez Fernández
- Division of Pediatric Neurology, Department of Pediatrics, Boston Medical Center, The Boston University Chobanian and Avedisian School of Medicine, USA.
| | - Marina Gaínza-Lein
- Instituto de Pediatría, Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Marta Amengual-Gual
- Pediatric Neurology Unit, Department of Pediatrics, Hospital Universitari Son Llàtzer, Universitat de les Illes Balears, Palma, Spain
| | - Cristina Barcia Aguilar
- Department of Child Neurology, Hospital Universitario La Paz, Universidad Autónoma de Madrid, Madrid, Spain
| | - Amanda Romeu
- Division of Pediatric Neurology, Department of Pediatrics, Boston Medical Center, The Boston University Chobanian and Avedisian School of Medicine, USA
| | - Alcy Torres
- Division of Pediatric Neurology, Department of Pediatrics, Boston Medical Center, The Boston University Chobanian and Avedisian School of Medicine, USA
| | - Rinat Jonas
- Division of Pediatric Neurology, Department of Pediatrics, Boston Medical Center, The Boston University Chobanian and Avedisian School of Medicine, USA
| | - Laurie M Douglass
- Division of Pediatric Neurology, Department of Pediatrics, Boston Medical Center, The Boston University Chobanian and Avedisian School of Medicine, USA
| |
Collapse
|
9
|
Gunasekera CL, Sirven JI, Feyissa AM. The evolution of antiseizure medication therapy selection in adults: Is artificial intelligence -assisted antiseizure medication selection ready for prime time? J Cent Nerv Syst Dis 2023; 15:11795735231209209. [PMID: 37868934 PMCID: PMC10586013 DOI: 10.1177/11795735231209209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/05/2023] [Indexed: 10/24/2023] Open
Abstract
Antiseizure medications (ASMs) are the mainstay of symptomatic epilepsy treatment. The primary goal of pharmacotherapy with ASMs in epilepsy is to achieve complete seizure remission while minimizing therapy-related adverse events. Over the years, more ASMs have been introduced, with approximately 30 now in everyday use. With such a wide variety, much guidance is needed in choosing ASMs for initial therapy, subsequent replacement monotherapy, or adjunctive therapy. The specific ASMs are typically tailored by the patient's related factors, including epilepsy syndrome, age, sex, comorbidities, and ASM characteristics, including the spectrum of efficacy, pharmacokinetic properties, safety, and tolerability. Weighing these key clinical variables requires experience and expertise that may be limited. Furthermore, with this approach, patients may endure multiple trials of ineffective treatments before the most appropriate ASM is found. A more reliable way to predict response to different ASMs is needed so that the most effective and tolerated ASM can be selected. Soon, alternative approaches, such as deep machine learning (ML), could aid the individualized selection of the first and subsequent ASMs. The recognition of epilepsy as a network disorder and the integration of personalized epilepsy networks in future ML platforms can also facilitate the prediction of ASM response. Augmenting the conventional approach with artificial intelligence (AI) opens the door to personalized pharmacotherapy in epilepsy. However, more work is needed before these models are ready for primetime clinical practice.
Collapse
|
10
|
Terman SW, Niznik JD, Growdon ME, Gerlach LB, Burke JF. Secular Trends in Central Nervous System-Active Polypharmacy Among Serial Cross-Sections of US Adults, 2009-2020. Drugs Aging 2023; 40:941-951. [PMID: 37695395 PMCID: PMC10629698 DOI: 10.1007/s40266-023-01066-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Data comprehensively examining trends in central nervous system (CNS)-active polypharmacy are limited. The objective of this cross-sectional study was to characterize the composition of and trends in CNS-active medication use in US adults. METHODS We included all participants ≥ 18 years old in the National Health and Nutrition Examination Study (NHANES), 2009-2020. The primary outcome was the percent of adults with CNS-active polypharmacy. This was defined as ≥ 3 medications among antidepressants [tricyclic, selective and serotonin-norepinephrine reuptake inhibitors (SSRIs and SNRIs), opioids, antiepileptics, antipsychotics, benzodiazepines, and nonbenzodiazepine receptor agonists ("Z-drugs")]. Secondary outcomes included prevalence of any CNS-active medication and specific medications and classes over time, and their indications. Percentages were weighted according to NHANES's nationally representative sampling frame. log binomial regressions evaluated the relative risk (RR) for each outcome, comparing the last (2017-2020) versus the first (2010-2011) survey cycle. RESULTS We included 34,189 adults (18.8% at least 65 years old) from five serial cross-sections (survey cycles). The prevalence of CNS-active polypharmacy was 2.1% in 2009-2010 and 2.6% in 2017-2020 [RR 1.18, 95% confidence interval (CI) 0.94-1.47]. The prevalence of CNS-active polypharmacy did not significantly change within any specific age group (e.g., age at least 65 years: RR 1.29, CI 0.74-2.24). The prevalence of any CNS-active medication was 21.0% in 2009 and 24.6% in 2017-2020 (RR] 1.12, 95% CI 1.02-1.25). A substantial increase occurred for antiepileptics (5.1-8.3%), specifically among participants aged 65 years and older (8.3-13.7%). This was largely driven by increasing gabapentin prevalence (1.4-3.6% overall; 3.3-7.9% age 65 years and older). Anticholinergic, SSRIs/SNRIs, antiepileptics, and benzodiazepines were elevated in most cycles for participants at least 65 years old compared with participants less than 65 years, and opioid use was increased in several cycles for older participants as well. Alprazolam was the most common benzodiazepine and third most common medication for anxiety/depression. Gabapentin was the most common CNS-active medication (3.6% of all participants in 2017-2020), followed by sertraline, citalopram, and acetaminophen-hydrocodone (each ~2%). The most common categories were antidepressants (13.7% in 2017-2020), followed by opioids (5.1% in 2017-2020). CONCLUSIONS CNS-active medications are increasingly common, particularly gabapentin, and use of any CNS-active medication increased by 12%. Numerous CNS-active classes also increased in older adults throughout the years. Increasing suboptimal medication use highlight the need for further investigation into causes for potentially inappropriate prescribing, particularly for older adults.
Collapse
Affiliation(s)
- Samuel W Terman
- Department of Neurology, University of Michigan, Taubman 1st Floor, Reception C, 1500 E Medical Center Dr, SPC 5316, Ann Arbor, MI, 48109, USA.
| | - Joshua D Niznik
- Division of Geriatric Medicine, Center for Aging and Health, School of Medicine, University of North Carolina At Chapel Hill, Chapel Hill, NC, USA
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina At Chapel Hill, Chapel Hill, NC, USA
| | - Matthew E Growdon
- Division of Geriatrics, University of California San Francisco, San Francisco, CA, USA
| | - Lauren B Gerlach
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - James F Burke
- Department of Neurology, The Ohio State University, Columbus, OH, USA
| |
Collapse
|
11
|
Moontaha S, Arnrich B, Galka A. State Space Modeling of Event Count Time Series. ENTROPY (BASEL, SWITZERLAND) 2023; 25:1372. [PMID: 37895494 PMCID: PMC10606130 DOI: 10.3390/e25101372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/02/2023] [Accepted: 09/19/2023] [Indexed: 10/29/2023]
Abstract
This paper proposes a class of algorithms for analyzing event count time series, based on state space modeling and Kalman filtering. While the dynamics of the state space model is kept Gaussian and linear, a nonlinear observation function is chosen. In order to estimate the states, an iterated extended Kalman filter is employed. Positive definiteness of covariance matrices is preserved by a square-root filtering approach, based on singular value decomposition. Non-negativity of the count data is ensured, either by an exponential observation function, or by a newly introduced "affinely distorted hyperbolic" observation function. The resulting algorithm is applied to time series of the daily number of seizures of drug-resistant epilepsy patients. This number may depend on dosages of simultaneously administered anti-epileptic drugs, their superposition effects, delay effects, and unknown factors, making the objective analysis of seizure counts time series arduous. For the purpose of validation, a simulation study is performed. The results of the time series analysis by state space modeling, using the dosages of the anti-epileptic drugs as external control inputs, provide a decision on the effect of the drugs in a particular patient, with respect to reducing or increasing the number of seizures.
Collapse
Affiliation(s)
- Sidratul Moontaha
- Digital Health—Connected Healthcare, Hasso Plattner Institute, University of Potsdam, 14482 Potsdam, Germany
| | - Bert Arnrich
- Digital Health—Connected Healthcare, Hasso Plattner Institute, University of Potsdam, 14482 Potsdam, Germany
| | - Andreas Galka
- Bundeswehr Technical Centre for Ships and Naval Weapons, Maritime Technology and Research (WTD 71), 24340 Eckernförde, Germany
| |
Collapse
|
12
|
Yi JQ, Huang S, Wu MJ, Ma JH, Huang LJ, Liang S, Sun D. Comparison of the effectiveness and safety of perampanel and oxcarbazepine as monotherapy in children and adolescents with newly diagnosed focal epilepsy. Front Pharmacol 2023; 14:1189058. [PMID: 37711169 PMCID: PMC10499172 DOI: 10.3389/fphar.2023.1189058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 08/14/2023] [Indexed: 09/16/2023] Open
Abstract
Objective: This study aims to compare the effectiveness and safety of perampanel and oxcarbazepine as monotherapy in children with focal epilepsy (FE). Methods: This is an ambispective, single-center, non-inferiority study comparing the effectiveness and safety of perampanel (PER) monotherapy and oxcarbazepine (OXC) monotherapy in children with newly diagnosed FE. The primary endpoint was a six-month seizure freedom rate. The secondary endpoints included retention, responder, and seizure freedom rates at 3, 6, and 12 months, respectively. Adverse events (AEs) were also recorded for both groups. Results: One hundred and thirty children and adolescents aged from 4 to 18years newly diagnosed with FE between May 2020 and November 2022 in Wuhan Children's Hospital were included. There were 71 patients in the PER group and 59 patients in the OXC group. In the per protocol set (PPS), 50 (78.1%) in the PER group and 43 (78.2%) in the OXC group completed six months of treatment without seizures. The lower 95% CI (66.0%-87.5%) limit of PER was higher than the non-inferiority margin of 62.4% (80% of the 6-month seizure freedom rate in the OXC group); PER was non-inferior to OXC. The 3-month and 12-month seizure freedom rates were 77.1% and 82.9% for the PER group, respectively, while they were 80.4% and 75.8% for the OXC group. There were no serious adverse events in both groups. Conclusion: PER showed comparable effectiveness and safety compared with OXC in children with newly diagnosed focal epilepsy, which might be an effective and safe treatment for children and adolescents with newly diagnosed FE. Clinical Trial Registration: Identifier ChiCTR2300074696.
Collapse
Affiliation(s)
- Jia-Qin Yi
- Department of Neurology, Wuhan Children’s Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Sheng Huang
- Department of Neurology, Wuhan Children’s Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Miao-Juan Wu
- Department of Neurology, Wuhan Children’s Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jie-Hui Ma
- Department of Neurology, Wuhan Children’s Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Li-Juan Huang
- Department of Neurology, Wuhan Children’s Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Song Liang
- Department of Pediatric Rehabilitation, Hubei the Third People’s Hospital, Wuhan, China
| | - Dan Sun
- Department of Neurology, Wuhan Children’s Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
13
|
Perdani RRW, Arozal W, Mangunatmadja I, Kaswandani N, Handryastuti S, Medise BE, Hardi H, Thandavarayan RA, Oswari H. The efficacy and safety of first-line anti-seizure medications as substitution therapy for children with drug-resistant epilepsy: a randomized controlled trial protocol. Front Neurol 2023; 14:1237183. [PMID: 37609651 PMCID: PMC10440385 DOI: 10.3389/fneur.2023.1237183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 07/26/2023] [Indexed: 08/24/2023] Open
Abstract
Although many anti-seizure medications (ASMs) are available, treatment failure, known as drug-resistant epilepsy (DRE), still occurs in around 30% of children with epilepsy. Second-line ASMs are usually used as substitution therapy in DRE to control seizures, although international consensus is not available yet. Previous studies focus on comparing the ASMs, whether as add-on or substitution therapy, mainly conducted in newly diagnosed epilepsy. However, the study that investigated first-line ASMs as substitution therapy compared to second-line ones, particularly among DRE children, is still lacking. A randomized controlled trial (RCT) enrolling 102 participants, aged 1-18, at three referral hospitals in Indonesia will be conducted, dividing them into intervention and control groups. The intervention group will be treated with first-line ASMs as the substitution therapy, while the other in the control group will get second-line ASMs. The primary outcome measure is the proportion difference of responders between groups who get first-line and second-line ASMs in 14 weeks of intervention. Clinical trial registration: ClinicalTrials.gov, identifier NCT05697614.
Collapse
Affiliation(s)
- Roro Rukmi Windi Perdani
- Department of Child Health, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
- Department of Child Health, Faculty of Medicine, University of Lampung, Bandar Lampung, Lampung, Indonesia
| | - Wawaimuli Arozal
- Department of Pharmacology and Therapeutics, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Irawan Mangunatmadja
- Department of Child Health, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Nastiti Kaswandani
- Department of Child Health, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Setyo Handryastuti
- Department of Child Health, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Bernie Endyarni Medise
- Department of Child Health, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Harri Hardi
- Department of Pharmacology and Therapeutics, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | | | - Hanifah Oswari
- Department of Child Health, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| |
Collapse
|
14
|
Xue H, Zeng L, He H, Xu D, Ren K. Effectiveness of acupuncture as auxiliary combined with Western medicine for epilepsy: a systematic review and meta-analysis. Front Neurosci 2023; 17:1203231. [PMID: 37547148 PMCID: PMC10397512 DOI: 10.3389/fnins.2023.1203231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/03/2023] [Indexed: 08/08/2023] Open
Abstract
Background Although more and more clinical studies have shown that acupuncture as an auxiliary combined with Western medicine is effective in the treatment of patients with epilepsy, no systematic reviews of acupuncture as a treatment for epilepsy have been published. Hence, we conducted this meta-analysis to evaluate the effect of acupuncture treatment on patients with epilepsy. Methods This study retrieved randomized controlled trials (RCTs) of acupuncture treatment for epilepsy from various electronic databases including PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Chinese BioMedical Literature Database, and Wangfang database. These studies evaluated the effectiveness of acupuncture as an auxiliary treatment combined with Western medicine for patients with epilepsy. The methodological quality of the studies was assessed using the Cochrane Handbook for Systematic Reviews of Interventions. Results A total of 17 RCTs involving a total of 1,389 participants were included. The results showed that acupuncture combined with Western medicine improved the effective rates of treatment (OR: 4.28; 95% CI: 3.04-6.02; p < 0.001), and reduced the seizure frequency of patients (SMD: -3.29; 95% CI: -3.51 to -3.07; p < 0.001) and the EEG discharge frequency (SMD: -5.58; 95% CI: -7.02 to -4.14; p < 0.001). Regarding the quality of life and adverse events, the acupuncture group was superior to the control group in improving the overall quality of life of patients with epilepsy (SMD: 14.41; 95% CI: 12.51-16.32; p < 0.001) and decreased adverse events (OR: 0.38; 95% CI: 0.23-0.63, p < 0.001). Conclusion The results of the analysis suggested that acupuncture combined with Western medicine is probably helpful in patients with epilepsy, but strong supportive data are not yet available. Given that this study is based on a low to moderate evidence-based analysis, the conclusions should be viewed with caution. Systematic review registration PROSPERO, identifier no. CRD42023409923.
Collapse
Affiliation(s)
- Hua Xue
- Department of Neurology, Sichuan Taikang Hospital, Chengdu, Sichuan, China
| | - Li Zeng
- Department of Respiratory, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, Guangxi, China
| | - Hongxian He
- Department of Neurology, Sichuan Taikang Hospital, Chengdu, Sichuan, China
| | - Dongxun Xu
- Department of Neurology, Sichuan Taikang Hospital, Chengdu, Sichuan, China
| | - Kaixin Ren
- Department of Rehabilitation, Affiliated Hospital of Yunnan University, Kunming, Yunnan, China
| |
Collapse
|
15
|
Blank LJ, Agarwal P, Kwon CS, Jetté N. Association of first anti-seizure medication choice with injuries in older adults with newly diagnosed epilepsy. Seizure 2023; 109:20-25. [PMID: 37178662 PMCID: PMC10686518 DOI: 10.1016/j.seizure.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/05/2023] [Accepted: 05/07/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Epilepsy incidence increases exponentially in older adults, who are also at higher risk of adverse drug effects. Anti-seizure medications (ASM) may be associated with sedation and injuries, but discontinuation can result in seizures. We sought to determine whether there was an association between prescribing non-guideline concordant ASM and subsequent injury as this could inform care models. METHODS Retrospective cohort study of adults 50 years or older with newly-diagnosed epilepsy in 2015-16, sampled from the MarketScan Databases. The outcome of interest was injury within 1-year of ASM prescription (e.g., burns, falls) and the exposure of interest was ASM category (recommended vs. not recommended by clinical guidelines). Descriptive statistics characterized covariates and a multivariable Cox-regression model was built to examine the association between ASM category and subsequent injury. RESULTS 5,931 people with newly diagnosed epilepsy were prescribed an ASM within 1-year. The three most common ASMs were: levetiracetam (62.86%), gabapentin (11.73%), and phenytoin (4.45%). Multivariable Cox-regression found that medication category was not associated with injury; however, older age (adjusted hazard ratio (AHR) 1.01/year), history of prior injury (AHR 1.77), traumatic brain injury (AHR 1.55) and ASM polypharmacy (AHR 1.32) were associated with increased hazard of injury. CONCLUSIONS Most older adults appear to be getting appropriate first prescriptions for epilepsy. However, a substantial proportion still receives medication that guidelines suggest avoiding. In addition, we show that ASM polypharmacy is associated with an increased hazard of injury within 1- year. Efforts to improve prescribing in older adults with epilepsy should consider how to reduce. both polypharmacy and exposure to medications that guidelines recommend avoiding.
Collapse
Affiliation(s)
- Leah J Blank
- Department of Neurology, Division of Health Outcomes & Knowledge Translation Research, Icahn school of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1137, New York, NY, United States; Department of Population Health and Policy, Institute for Healthcare Delivery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY, United States.
| | - Parul Agarwal
- Department of Neurology, Division of Health Outcomes & Knowledge Translation Research, Icahn school of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1137, New York, NY, United States; Department of Population Health and Policy, Institute for Healthcare Delivery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY, United States
| | - Churl-Su Kwon
- Departments of Neurology, Epidemiology, Neurosurgery and the Gertrude H. Sergievsky Center, Columbia University, 622 West 168th Street, New York, NY PH19-106, United States
| | - Nathalie Jetté
- Department of Neurology, Division of Health Outcomes & Knowledge Translation Research, Icahn school of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1137, New York, NY, United States; Department of Population Health and Policy, Institute for Healthcare Delivery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY, United States
| |
Collapse
|
16
|
Mayerhofer E, Parodi L, Narasimhalu K, Wolking S, Harloff A, Georgakis MK, Rosand J, Anderson CD. Genetic variation supports a causal role for valproate in prevention of ischemic stroke. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.02.14.23285856. [PMID: 36865155 PMCID: PMC9980256 DOI: 10.1101/2023.02.14.23285856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Valproate is a candidate for ischemic stroke prevention due to its anti-atherosclerotic effects in vivo. Although valproate use is associated with decreased ischemic stroke risk in observational studies, confounding by indication precludes causal conclusions. To overcome this limitation, we applied Mendelian randomization to determine whether genetic variants that influence seizure response among valproate users associate with ischemic stroke. We derived a genetic score for valproate response using genome-wide association data of seizure response after valproate intake from the Epilepsy Pharmacogenomics Consortium. We then tested this score among valproate users of the UK Biobank for association with incident and recurrent ischemic stroke using Cox proportional hazard models. Among 2,150 valproate users (mean 56 years, 54% females), 82 ischemic strokes occurred over a mean 12-year follow-up. Higher valproate response genetic score was associated with higher serum valproate levels (+5.78 μg/ml per one SD, 95% CI [3.45, 8.11]). After adjusting for age and sex, higher valproate response genetic score was associated with lower ischemic stroke risk (HR per one SD 0.73, [0.58, 0.91]) with a halving of absolute risk in the highest compared to the lowest score tertile (4.8% vs 2.5%, p-trend=0.027). Among 194 valproate users with prevalent stroke at baseline, a higher valproate response genetic score was associated with lower recurrent ischemic stroke risk (HR per one SD 0.53, [0.32, 0.86]) with reduced absolute risk in the highest compared to the lowest score tertile (3/51, 5.9% vs. 13/71, 18.3%, p-trend=0.026). The valproate response genetic score was not associated with ischemic stroke among the 427,997 valproate non-users (p=0.61), suggesting minimal pleiotropy. In an independent cohort of 1,241 valproate users of the Mass General Brigham Biobank with 99 ischemic stroke events over 6.5 years follow-up, we replicated our observed associations between the valproate response genetic score and ischemic stroke (HR per one SD 0.77, 95% CI: [0.61, 0.97]). These results demonstrate that a genetically predicted favorable seizure response to valproate is associated with higher serum valproate levels and reduced ischemic stroke risk among valproate users, providing causal support for valproate effectiveness in ischemic stroke prevention. The strongest effect was found for recurrent ischemic stroke, suggesting potential dual-use benefits of valproate for post-stroke epilepsy. Clinical trials will be required in order to identify populations that may benefit most from valproate for stroke prevention.
Collapse
Affiliation(s)
- Ernst Mayerhofer
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
- Program in Medical and Population Genetics, Broad Institute of Harvard and the Massachusetts Institute of Technology, Boston, MA, USA
- McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
| | - Livia Parodi
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
- Program in Medical and Population Genetics, Broad Institute of Harvard and the Massachusetts Institute of Technology, Boston, MA, USA
- McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Kaavya Narasimhalu
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
- Program in Medical and Population Genetics, Broad Institute of Harvard and the Massachusetts Institute of Technology, Boston, MA, USA
- McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
| | - Stefan Wolking
- Department of Neurology and Epileptology, University Hospital Aachen, Germany
| | - Andreas Harloff
- Department of Neurology and Neurophysiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Marios K Georgakis
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
- Program in Medical and Population Genetics, Broad Institute of Harvard and the Massachusetts Institute of Technology, Boston, MA, USA
- McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
- Institute for Stroke and Dementia Research (ISD), University Hospital, Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
| | - Jonathan Rosand
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
- Program in Medical and Population Genetics, Broad Institute of Harvard and the Massachusetts Institute of Technology, Boston, MA, USA
- McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher D Anderson
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
- Program in Medical and Population Genetics, Broad Institute of Harvard and the Massachusetts Institute of Technology, Boston, MA, USA
- McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| |
Collapse
|
17
|
Leppien EE, Doughty BJ, Hurd KL, Strong KN, Piper BJ, McCall KL. Newer Antiseizure Medications and Suicidality: Analysis of the Food and Drug Administration Adverse Event Reporting System (FAERS) Database. Clin Drug Investig 2023:10.1007/s40261-023-01272-9. [PMID: 37184612 DOI: 10.1007/s40261-023-01272-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND The association between antiseizure medications (ASMs) and suicidality remains controversial. Analyses of additional datasets are needed to further elucidate the complex relationship between antiseizure medications and suicidality. OBJECTIVE The aim of this study was to compare the safety profile of newer ASMs with older ASMs through an analysis of the US Food and Drug Administration Adverse Event Reporting System (FAERS) database, with a focus on suicidality. METHODS We queried over 17 million reports in the FAERS database from 2012 to 2021 and identified cases involving ASMs. After removing incomplete and duplicate reports, the study cohort consisted of lacosamide (n = 7593), perampanel (n = 1813), clobazam (n = 3827), brivaracetam (n = 1166), and vigabatrin (n = 5293) compared with a control group of older ASMs (topiramate, lamotrigine, valproic acid, carbamazepine, levetiracetam; n = 71,535). Cases of suicidality (completed suicide, suicidal ideation, attempted suicide, suicidal behavior, suicidal depression) were identified in each group. Adjusted (age and sex) odds ratios (aOR) and associated 95% confidence intervals (CI) were calculated using logistic regression analysis for each new drug when compared with the control group of older ASM drugs. RESULTS A total of 6309 cases of suicidality were identified among reports with ASMs. Most reports were sourced from healthcare professionals (5516, 87.4%). The proportion of reports involving suicidality were 210/7593 (2.8%) for lacosamide, 185/1813 (10.2%) for perampanel, 108/3827 (2.8%) for clobazam, 57/1166 (4.9%) for brivaracetam, 14/5293 (0.3%) for vigabatrin, and 5735/71,535 (8.0%) for older ASMs. Compared with older ASMs, the aOR for suicidality was 0.33 (95% CI 0.28-0.38) for lacosamide, 1.34 (95% CI 1.15-1.56) for perampanel, 0.35 (95% CI 0.29-0.43) for clobazam, 0.60 (95% CI 0.45-0.77) for brivaracetam, and 0.03 (95% CI 0.02-0.05) for vigabatrin. CONCLUSION When compared with older ASMs, four newer ASMs (lacosamide, clobazam, brivaracetam, and vigabatrin) were found to have significantly lower odds of suicidality, while perampanel was found to significantly increase the odds of suicidality. Pronounced variability (greater than 30 fold) in the proportion of FAERS reports associated with suicidality among the drugs studied was identified. The results of this case control study of FDA adverse event reports spanning 10 years and 6309 cases of suicidality expand our understanding of the safety profile of newer ASMs.
Collapse
Affiliation(s)
- Emily E Leppien
- Department of Pharmacy Practice, Binghamton University School of Pharmacy & Pharmaceutical Sciences, Johnson City, NY, 13790, USA
| | - Bennett J Doughty
- Department of Pharmacy Practice, Binghamton University School of Pharmacy & Pharmaceutical Sciences, Johnson City, NY, 13790, USA
| | - Karyssa L Hurd
- Binghamton University School of Pharmacy & Pharmaceutical Sciences, 96 Corliss Avenue, Johnson City, NY, 13790, USA
| | - Keira N Strong
- Binghamton University School of Pharmacy & Pharmaceutical Sciences, 96 Corliss Avenue, Johnson City, NY, 13790, USA
| | - Brian J Piper
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA, 18510, USA
- Geisinger Center for Pharmacy Innovation and Outcomes, Daville, PA, 17821, USA
| | - Kenneth L McCall
- Department of Pharmacy Practice, Binghamton University School of Pharmacy & Pharmaceutical Sciences, Johnson City, NY, 13790, USA.
| |
Collapse
|
18
|
Jaspersen SL, Bruns DA, Candee MS, Battaglia A, Carey JC, Fishler KP. Seizures in trisomy 18: Prevalence, description, and treatment. Am J Med Genet A 2023; 191:1026-1037. [PMID: 36601988 DOI: 10.1002/ajmg.a.63113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 12/20/2022] [Accepted: 12/22/2022] [Indexed: 01/06/2023]
Abstract
Changes in medical intervention over the last decade have improved outcomes for individuals with trisomy 18, the second most common human aneuploidy syndrome at birth. As children with trisomy 18 live longer, a shared concern of medical experts and parents is the occurrence and treatment of seizures. Previously published surveillance guidelines for this condition have not addressed seizure management. Using parent-reported data collected as part of the Tracking Rare Incidence Syndromes project, we report on the prevalence, course, and management of seizures in individuals with trisomy 18. Twenty-eight percent (52/186) of individuals diagnosed with trisomy 18 in our retrospective cohort experienced generalized, focal, or mixed seizures at some point in their lifetime. For many individuals, seizures were effectively managed by broad-spectrum anti-seizure medications. Correlation analysis showed that focal and generalized seizures were more likely to occur in individuals who had previously experienced infantile spasms or central apnea. Electroencephalogram testing should be considered as part of a standard screening approach in individuals with trisomy 18 to enable early diagnosis and treatment of seizures. An international registry that incorporates parent-reported and clinical data for patients with trisomy 18 may facilitate ongoing research and recruitment into clinical trials for seizure management.
Collapse
Affiliation(s)
- Sue L Jaspersen
- Genetic Counseling Program, Department of Medical Sciences, College of Allied Health Professions, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Deborah A Bruns
- Special Education Program, School of Education, Southern Illinois University Carbondale, Carbondale, Illinois, USA
| | - Meghan S Candee
- Division of Pediatric Neurology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Agatino Battaglia
- Department of Developmental Neuroscience, IRCCS Stella Maris Foundation, Pisa, Italy
| | - John C Carey
- Division of Medical Genetics, Department of Pediatrics, University of Utah Health, Salt Lake City, Utah, USA
| | - Kristen P Fishler
- Munroe-Meyer Institute for Genetics and Rehabilitation, University of Nebraska Medical Center, Omaha, Nebraska, USA
| |
Collapse
|
19
|
Kolaski K. Which antiepileptic drugs are safe and effective as monotherapy to treat focal and generalized seizures in adults and children? A Cochrane Review summary with commentary. Dev Med Child Neurol 2023; 65:158-161. [PMID: 36448606 DOI: 10.1111/dmcn.15473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 11/10/2022] [Indexed: 12/05/2022]
Affiliation(s)
- Kat Kolaski
- Wake Forest School of Medicine - Departments of Orthopedics and Pediatrics, Winston-Salem, NC, USA
| |
Collapse
|
20
|
Mann C, Maltseva M, von Podewils F, Knake S, Kovac S, Rosenow F, Strzelczyk A. Supply problems of antiseizure medication are common among epilepsy patients in Germany. Epilepsy Behav 2023; 138:108988. [PMID: 36423387 DOI: 10.1016/j.yebeh.2022.108988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/18/2022] [Accepted: 11/01/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the frequency of reported antiseizure medication (ASM) supply problems among patients with epilepsy (PWE) in Germany. METHODS The Epi2020 study was a multicenter study focusing on different healthcare aspects of adult PWE in Germany. In addition to basic clinical and demographic characteristics, PWE were asked to answer a questionnaire regarding supply difficulties regarding their ASM, and if they had to discontinue ASM treatment due to supply problems. Generic switch of medication was recorded, and adverse effects were measured using the Liverpool Adverse Events Profile (LAEP) scale. Data were analyzed to detect predictors of supply problems. RESULTS In total, 434 PWE with a mean age of 40 years (median 37 years, SD = 15.5, range: 18-83 years, 254 female) participated in this study. 53.7% of PWE (n = 233) reported that at least once in the past 12 months their ASM was not available at the pharmacy, and 24.9% (n = 108) reported having experienced ASM supply problems three times or more during the past 12 months. Patients with epilepsy treated with carbamazepine and zonisamide reported frequent problems with availability in 45.8% and 44.8% respectively, whereas those treated with lacosamide and valproate reported supply problems less frequently (17.0% and 16.4%, respectively). Nine patients (2.1%) were unable to take their ASM as prescribed at least once in the past 12 months due to supply problems. Forty-nine patients (11.3%) reported having to switch ASM due to supply difficulties with generic replacement occurring in 39.4% (n = 171) of patients. Those with supply problems were more likely to be treated with more ASMs and scored higher on the LAEP. CONCLUSION Supply problems with ASM are frequent among PWE in Germany and are reported for older and newer ASMs. Supply problems contribute to ASM nonadherence and are positively correlated with the number of ASM taken and adverse events.
Collapse
Affiliation(s)
- Catrin Mann
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany.
| | - Margarita Maltseva
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Felix von Podewils
- Department of Neurology, University Hospital Greifswald, Greifswald, Germany
| | - Susanne Knake
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg, Germany
| | - Stjepana Kovac
- Epilepsy Center Münster-Osnabrück, Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University, Münster, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
| |
Collapse
|
21
|
Kharel S, Ojha R, Khanal S. Levetiracetam versus Oxcarbazepine as monotherapy in newly diagnosed focal epilepsy: A systematic review and meta-analysis. Brain Behav 2022; 12:e2779. [PMID: 36184821 PMCID: PMC9660411 DOI: 10.1002/brb3.2779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/14/2022] [Accepted: 09/14/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To compare the efficacy and safety of Levetiracetam (LEV) and Oxcarbazepine (OXC) as monotherapy for the treatment of newly diagnosed focal epilepsy. METHODS We searched PubMed, Cochrane Library, EMBASE, and Google Scholar from January 1, 2000 to May 11, 2022, with no language restrictions along with The ClinicalTrials.gov website and the WHO International Controlled Trials Registry platforms. We pooled the risk ratio (RR) and corresponding 95% confidence interval (95% CI) for the efficacy and safety outcomes. The quality of included trials was assessed using the Cochrane Collaboration's tool. RESULTS Two RCTs included a total of 574 newly diagnosed focal epilepsy patients (the LEV group [282 patients] and the OXC group [292 patients]). LEV group when compared with the OXC group had no significant difference in the pooled estimate of seizure freedom at week 24. (RR: 0.81; 95% CI: 0.62-1.05, p = .11). Similarly, there was no significant difference in the pooled estimate of withdrawal due to adverse events (AEs) (RR: 0.87; 95% CI: 0.34-2.23, p = .77). The commonly reported AEs in both trials were dizziness, headache, rash, somnolence, and nasopharyngitis with zero medication-related death and few serious AEs. CONCLUSIONS LEV is noninferior to OXC in terms of seizure freedom at week 24 and treatment withdrawal rate due to AEs among adults but long-term treatment data is still missing. Future multicentric double-blinded RCTs and real-world studies are of great need.
Collapse
Affiliation(s)
- Sanjeev Kharel
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| | - Rajeev Ojha
- Department of Neurology, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Surendra Khanal
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| |
Collapse
|
22
|
Terman SW, Lin CC, Kerr WT, DeLott LB, Callaghan BC, Burke JF. Changes in the Use of Brand Name and Generic Medications and Total Prescription Cost Among Medicare Beneficiaries With Epilepsy. Neurology 2022; 99:e751-e761. [PMID: 35705496 PMCID: PMC9484734 DOI: 10.1212/wnl.0000000000200779] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 04/11/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVE To characterize trends in antiseizure medication (ASM) fills and total prescription costs in people with epilepsy. METHODS This was a retrospective cohort study of beneficiaries with epilepsy (ASM, plus ICD codes) in a 20% random Medicare sample, with continuous Fee-For-Service coverage (Parts A, B, and D) in 2008-2018. We summed the number of pill days and costs (adjusted to 2018 dollars) per person-year for each ASM. ASMs were categorized into brand vs generic, first vs newer generation, and enzyme inducers vs noninducers. RESULTS There were 77,000-133,000 beneficiaries with epilepsy per year. The most common ASM was phenytoin in 2008, which shifted to levetiracetam in 2018 (2008: phenytoin 25%, levetiracetam 14%; 2018: phenytoin 9%, levetiracetam 27%). Brand name (2008: 56%; 2018: 14%), first-generation (2008: 55%; 2018: 32%), and enzyme-inducing ASMs (2008: 44%; 2018: 24%) each decreased over time as a proportion of pill days. The number of brand pill days per person-year initially decreased (e.g., 2008: 250; 2009: 121; 2010: 96) but then plateaued (2013-2018: between 66 and 69) given a notable increase in lacosamide pill days per person (2008: 0; 2018: 20). Total brand name costs per year initially decreased 2008-2010 (2008: $150 million; 2010: $72 million) but then increased after 2010 (2018: $256 million). In 2018, brand name ASMs represented 79% of costs despite representing only 14% of pill days, a 1-year pill supply became 277% more expensive for brand name medications but 42% less expensive for generic medications over time (2008: brand ∼$2,800 vs generic ∼$800; 2018: brand ∼$10,700 vs generic ∼$460), and many common brand name ASMs cost approximately 10-fold more per pill day than their generic equivalents. DISCUSSION First-generation and enzyme-inducing ASMs waned from 2008 to 2018. Although brand name ASMs initially waned translating into lower costs and potentially higher value care, after 2010, brand name costs markedly increased because of increasing use of lacosamide plus a 277% increase in per-pill cost of brand name ASMs. Brand name ASMs represented a minority of prescriptions, but the majority of costs.
Collapse
Affiliation(s)
- Samuel W Terman
- From the Department of Neurology, University of Michigan, Ann Arbor, MI.
| | - Chun C Lin
- From the Department of Neurology, University of Michigan, Ann Arbor, MI
| | - Wesley T Kerr
- From the Department of Neurology, University of Michigan, Ann Arbor, MI
| | - Lindsey B DeLott
- From the Department of Neurology, University of Michigan, Ann Arbor, MI
| | - Brian C Callaghan
- From the Department of Neurology, University of Michigan, Ann Arbor, MI
| | - James F Burke
- From the Department of Neurology, University of Michigan, Ann Arbor, MI
| |
Collapse
|
23
|
Aquatic Freshwater Vertebrate Models of Epilepsy Pathology: Past Discoveries and Future Directions for Therapeutic Discovery. Int J Mol Sci 2022; 23:ijms23158608. [PMID: 35955745 PMCID: PMC9368815 DOI: 10.3390/ijms23158608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/29/2022] [Accepted: 07/30/2022] [Indexed: 12/04/2022] Open
Abstract
Epilepsy is an international public health concern that greatly affects patients’ health and lifestyle. About 30% of patients do not respond to available therapies, making new research models important for further drug discovery. Aquatic vertebrates present a promising avenue for improved seizure drug screening and discovery. Zebrafish (Danio rerio) and African clawed frogs (Xenopus laevis and tropicalis) are increasing in popularity for seizure research due to their cost-effective housing and rearing, similar genome to humans, ease of genetic manipulation, and simplicity of drug dosing. These organisms have demonstrated utility in a variety of seizure-induction models including chemical and genetic methods. Past studies with these methods have produced promising data and generated questions for further applications of these models to promote discovery of drug-resistant seizure pathology and lead to effective treatments for these patients.
Collapse
|
24
|
Kacirova I, Grundmann M, Brozmanova H. Carbamazepine and carbamazepine-epoxide concentrations in mothers, colostrum, and breastfed newborns: Comparison with concentrations determined during delivery and in the mature milk period. Biomed Pharmacother 2022; 151:113176. [PMID: 35623166 DOI: 10.1016/j.biopha.2022.113176] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/12/2022] [Accepted: 05/22/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To obtain information on the transport of carbamazepine and its active metabolite carbamazepine-epoxide from mother to colostrum and breastfed newborns. METHODS In this cohort study, carbamazepine and carbamazepine-epoxide concentrations in maternal serum (162 women), milk (i.e., colostrum) and breastfed newborn serum were analysed between the 1st and 5th days after delivery from November 1990 to February 2021. The measured concentrations were compared with the delivery and mature milk periods. The effect of the combination with both enzyme-inducing antiseizure medication and valproic acid was also evaluated. RESULTS Carbamazepine concentrations varied from 1.0 to 11.2 mg/L (epoxide 0.3-4.4 mg/L) in maternal serum, from 0.5 to 6.8 mg/L (epoxide 0.3-2.4 mg/L) in milk and from 0.5 to 4.7 mg/L (epoxide 0.3-1.7 mg/L) in newborn serum. The median milk/maternal serum concentration ratio of carbamazepine was 0.45 (epoxide 0.71), the median newborn/maternal serum concentration ratio of carbamazepine was 0.20 (epoxide 0.41), and the median newborn serum/milk concentration ratio of carbamazepine was 0.38 (epoxide 0.50). A highly significant correlation was found between the milk and maternal serum concentrations of both carbamazepine and carbamazepine-epoxide and between the milk and newborn serum concentrations of carbamazepine. CONCLUSIONS In the serum of breastfed newborns, only one concentration of carbamazepine reached the reference range used for the general epileptic population, and more than half was below the lower limit of quantification. Routine monitoring of serum carbamazepine concentrations is not required in breastfed newborns. However, observation of newborns is desirable, and if signs of potential adverse reactions are noted, the serum concentrations in newborns should be measured.
Collapse
Affiliation(s)
- Ivana Kacirova
- Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic; Department of Clinical Pharmacology, Institute of Laboratory Medicine, University Hospital Ostrava, 17. listopadu 1790, 700 30 Ostrava, Czech Republic
| | - Milan Grundmann
- Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic; Department of Clinical Pharmacology, Institute of Laboratory Medicine, University Hospital Ostrava, 17. listopadu 1790, 700 30 Ostrava, Czech Republic.
| | - Hana Brozmanova
- Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic; Department of Clinical Pharmacology, Institute of Laboratory Medicine, University Hospital Ostrava, 17. listopadu 1790, 700 30 Ostrava, Czech Republic
| |
Collapse
|
25
|
Zhu H, Deng X, Feng L, Lian Y, Han X, Guo Z, Gou Y, Du Y, Xie L, Yao D, Liu Y, Wu Q, Lan S, Liu K, Zhan P, Wang X, Dang J, Hou Y, Chen K, Zhu Y, Shi Y, Yu Y, Xiao B, Zhu S, Meng H. Efficacy comparison of oxcarbazepine and levetiracetam monotherapy among patients with newly diagnosed focal epilepsy in China: A multicenter, open-label, randomized study. CNS Neurosci Ther 2022; 28:1072-1080. [PMID: 35429132 PMCID: PMC9160445 DOI: 10.1111/cns.13840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 03/08/2022] [Accepted: 03/25/2022] [Indexed: 11/30/2022] Open
Abstract
Aims This multicenter, open‐label, randomized study (Registration No. ChiCTR‐OCH‐14004528) aimed to compare the efficacy and effects of oxcarbazepine (OXC) with levetiracetam (LEV) as monotherapies on patient quality of life and mental health for patients with newly diagnosed focal epilepsy from China. Methods Patients with newly diagnosed focal epilepsy who had experienced 2 or more unprovoked seizures at greater than a 24‐h interval during the previous year were recruited. Participants were randomly assigned to the OXC group or LEV group. Efficacy, safety, quality of life, and mental health were evaluated over 12‐week and 24‐week periods. Results In total, we recruited 271 newly diagnosed patients from 23 centers. Forty‐four patients were excluded before treatment for reasons. The rate of seizure freedom of OXC was significantly superior to that of LEV at 12 weeks and 24 weeks (p < 0.05). The quality of life (except for the seizure worry subsection) and anxiety scale scores also showed significant differences from before to after treatment in the OXC and LEV groups. Conclusions OXC monotherapy may be more effective than LEV monotherapy in patients with newly diagnosed focal epilepsy. Both OXC and LEV could improve the quality of life and anxiety state in adult patients with focal epilepsy.
Collapse
Affiliation(s)
- Haoyue Zhu
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Xuejun Deng
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Li Feng
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Yajun Lian
- Department of Neurology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiong Han
- Department of Neurology, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China
| | - Zhenli Guo
- Department of Neurology, Hubei Provincial Hospital of Integrated Chinese and Western Medicine, Wuhan, China
| | - Yulan Gou
- Department of Neurology, Wuhan No. 1 Hospital, Wuhan, China
| | - Yuanmin Du
- Department of Neurology, Wuhan General Hospital of the YANGTZE River Shipping, Wuhan, China
| | - Longshan Xie
- Department of Functional Neuroscience, The First People's Hospital of Foshan, Foshan, China
| | - Dongai Yao
- Department of Neurology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Yonghong Liu
- Department of Neurology, Xijing Hospital of Air Force Military Medical University, Xi'an, China
| | - Qiang Wu
- Department of Neurology, Wuhan General Hospital of PLA, Wuhan, China
| | - Song Lan
- Department of Internal Medicine-Neurology, Maoming People's Hospital of Guangdong Province, Maoming, China
| | - Kaisheng Liu
- Department of Neurology, Taihe Hospital, Shiyan, China
| | - Peiyan Zhan
- Department of Neurology, The Central Hospital of Wuhan, Wuhan, China
| | - Xiahong Wang
- Department of Neurology, Zhengzhou Second Hospital, Zhengzhou, China
| | - Jingxia Dang
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yunqi Hou
- Department of Neurology, Shunde First Affiliated Hospital of Southern Medical University, Shunde, China
| | - Keqiang Chen
- Department of Neurology, Central Hospital of Jiangmen, Jiangmen, China
| | - Yulan Zhu
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yuliang Shi
- Department of Neurology, People's Hospital of Meizhou, Meizhou, China
| | - Yunli Yu
- Department of Neurology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Bo Xiao
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Suiqiang Zhu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hongmei Meng
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| |
Collapse
|
26
|
Chen Y, Wang Q, Xu Y, Wu D, Xu L, Zhu G, Wu X. Comparison of Lamotrigine and Oxcarbazepine Monotherapy Among Chinese Adult Patients With Newly-Diagnosed Focal-Onset Epilepsy: A Prospective Observational Study. Front Neurol 2022; 13:855498. [PMID: 35756921 PMCID: PMC9226306 DOI: 10.3389/fneur.2022.855498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 05/11/2022] [Indexed: 11/24/2022] Open
Abstract
Objective We performed a prospective cohort study to compare the efficacy, safety, effect on mood, and quality of life between lamotrigine (LTG) and oxcarbazepine (OXC) monotherapy among Chinese adult patients with newly-diagnosed focal-onset epilepsy (FOE) with or without secondarily generalized tonic-clonic seizures. Methods We enrolled 106 adult patients with new-onset FOE, of whom 56 were in the OXC group and 50 in the LTG group. Their clinical characteristics were detailly recorded especially basic seizure frequency, seizure types, and drug-related adverse events. Efficacy was evaluated as seizure-free (no seizure for 6 months), effective (seizure reduction by more than 50%), and ineffective (seizure reduction by less than 50%). Both intention-to-treat and per-protocol analyses were performed. We also assessed their mood state with the Zung Self-rating Scale for anxiety (Z-SAS) and Zung Self-rating Scale for Depression (Z-SDS) and quality of life (QOL) with Quality of Life in Epilepsy (QOLIE-31) at their baseline visit, 3-month visits, and 6-month visit. Intra-group comparisons in each group and inter-group comparisons between the two groups were made. Correlation analysis and multiple regression analysis were also conducted. Results Except for gender, the two groups were well matched in any other characteristics such as primary seizure frequency and seizure types. In terms of efficacy, 33 patients in the OXC group were evaluated as seizure-free and 15 as effective, while in the LTG group, 31 were seizure-free, and nine were effective. No significant differences could be observed in efficacy between the two groups (P = 0.429). Through multiple logistic regression analysis, we found that OXC monotherapy was more likely to predict a seizure-free state (OR = 1.76) than LTG, but the difference didn't reach statistical significance (P = 0.322) after correcting for other clinical variables. Both groups had adverse events such as fatigue, drowsiness, dizziness, rash, and gastrointestinal discomfort, most of which were mild and transient. In the OXC group, the scores of SAS (P = 0.067) and SDS (P = 0.004) reduced at the 6-month visit, while the score of QOLIE-31 significantly increased (P = 0.001). In the LTG group, a significant decrease in SAS and SDS scores and an increase in QOLIE-31 scores could be witnessed (All P < 0.001). The inter-group comparison showed that improvement of SAS and SDS in the LTG group was more evident than that in the OXC group, which was of statistical significance. Correlational analysis indicated that the improvement of mood and life quality scales in both groups was independent of baseline seizure frequency and treatment efficacy. Multiple linear regression analysis indicated that LTG monotherapy was the only independent factor that could predict a better SAS (P = 0.01) and SDS (P = 0.019) outcome. Conclusions OXC and LTG are effective as monotherapy and can be considered first-line selection among adult patients with new-onset FOE. Most adverse events are mild, transient, and tolerable. The two drugs improve the mood state of patients, though LTG is superior to OXC in this respect. OXC and LTG have great power in enhancing patients' quality of life. The positive effect on the psychosocial well-being of epilepsy patients may be one of the intrinsic pharmacological properties of LTG and OXC.
Collapse
Affiliation(s)
- Yuncan Chen
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Qinyue Wang
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ye Xu
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Dongyan Wu
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China
| | - Lan Xu
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China
| | - Guoxing Zhu
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China
| | - Xunyi Wu
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China
| |
Collapse
|
27
|
Satishchandra P, Rathore C, Apte A, Kumar A, Mandal A, Chauhan D, Agadi J, Gurumukhani J, Asokan K, Venkateshwarlu K, Lingappa L, Sundaracharya NV, Jha SK, Ravat S, Vk S, Garg S, Shah SV, Alagesan S, Razdan S, Padhy U, Agarwal VK, Arora V, Menon B, Shetty S, Chodankar D. Evaluation of one-year effectiveness of clobazam as an add-on therapy to anticonvulsant monotherapy in participants with epilepsy having uncontrolled seizure episodes: An Indian experience. Epilepsy Behav 2022; 130:108671. [PMID: 35381495 DOI: 10.1016/j.yebeh.2022.108671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/14/2022] [Accepted: 03/15/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To prospectively study the effectiveness and safety of clobazam as an add-on therapy in patients with epilepsy whose seizures are not adequately controlled with antiseizure medicine (ASM) monotherapy. METHODS We conducted a prospective, observational study at 28 neurology outpatient clinics in India from June 2017 to October 2019. Consecutive patients with epilepsy (older than 3 years) with inadequate seizure control with ASM monotherapy were initiated on clobazam. Patients were followed up at 1, 3, 6, 9, and 12 months. Seizure control and adverse events were assessed through personal interviews and seizure diaries. RESULTS Out of 475 eligible patients, data of 429 patients (men: 65.5%) were evaluated (46 excluded due to protocol deviations). The median age was 25 (range, 3-80 years) years and the median duration of epilepsy was 3 (0.1-30) years. The majority of patients had focal epilepsy (55.0%) and genetic generalized epilepsy (40.1%). The one-year follow-up was completed by 380 (88.5%) patients. At one-year follow-up, 317 (83.4%; N = 380) patients in the study remained seizure free. These 317 patients who were seizure free at 12 months comprised 73.9% of the evaluable population (N = 429). In 98.8% of patients, the primary reason for adding clobazam was inadequate control of seizures with treatment. During one-year follow-up, a total of 113 (22.6%) patients experienced at least one adverse event which included 103 (20.6%) patients who experienced 386 episodes of seizures. CONCLUSION The study provides preliminary evidence that clobazam is effective and well-tolerated as add-on therapy for a period of one year among patients with epilepsy inadequately stabilized with monotherapy. TRIAL REGISTRATION NUMBER CTRI/2017/12/010906.
Collapse
Affiliation(s)
| | - Chaturbhuj Rathore
- Department of Neurology, SBKS Medical Institute Research Centre, Vadodara, Gujarat, India.
| | - Anirudha Apte
- Department of Neurology, Institute of Neurosciences, Surat, India
| | - Abhishek Kumar
- Department of Neurology, Paras HMRI Hospital, Patna, India
| | - Amlan Mandal
- Department of Neurology, KPC Medical College & NH (Kolkata) AMRI Hospitals, Kolkata, India
| | | | | | | | - K Asokan
- Neurology Department, Sri Ramkrishna Hospital, Coimbatore, India
| | | | | | | | | | | | - Sanjeev Vk
- Muthoot Healthcare Private Limited, College Road, Kozchecherry, Kerala, India
| | | | | | - Sundaram Alagesan
- Medicine, Tirunelveli Medical College, Tirunelveli, Tamil Nadu, India
| | | | - Uma Padhy
- Department of Neurology, MKCG Medical College and Hospital, Behrampur, Odisha, India
| | | | - Vinod Arora
- Dhanvantari Jeevan Rekha Hospital, Meerut, India
| | - Bindu Menon
- Neurology, Apollo Speciality Hospitals, Nellore, India
| | | | | |
Collapse
|
28
|
Tunwongsa K, Chonnawakul M, Geratikornsupuk N, Tewthanom K. Genetic screening to avoid adverse drug reactions from medication use and approach patients' better outcomes: A lesson learn from the report of the Queen Savang Vadhana Memorial Hospital. Health Sci Rep 2022; 5:e591. [PMID: 35509409 PMCID: PMC9059221 DOI: 10.1002/hsr2.591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 11/29/2022] Open
Abstract
Background and Aims The polymerase chain reaction (PCR) technique is adopted for pharmacogenetic testing and adverse drug reaction (ADR) analysis. Methods: PCR was used for testing of pharmacogenetic markers for HLA and non‐HLA polymorphism related to specific drugs. Results Among 76 cases that underwent genetic screening, 7.7%, 11.1%, and 2.7% of the patients were found to be genetically positive for allopurinol, carbamazepine, and abacavir, respectively. Two cases were genetically positive for interferon, and two cases of extensive metabolizers were positive for clopidogrel. One case of a NAT2 slow acetylator for isoniazid was found. Among the 74 cases with complete outcomes, 39.2% showed improvements and 18.9% reported a deterioration. Although no serious ADR was observed, two HLA‐B*5701‐negative cases reported ADRs (2.7%). All patients positive for IL28B were improved. One patient receiving clopidogrel showed improvements, but another showed deterioration. Finally, the outcome of slow acetylation NAT2 was worse without ADR. Conclusion PCR‐based pharmacogenetic testing is critical for ADR monitoring in a cost‐effective manner.
Collapse
Affiliation(s)
- Kessada Tunwongsa
- Department of Pharmacy Queen Savang Vadhana Memorial Hospital Chonburi Thailand
| | - Malinee Chonnawakul
- Department of Pharmacy Queen Savang Vadhana Memorial Hospital Chonburi Thailand
| | | | | |
Collapse
|
29
|
Spotnitz M, Ostropolets A, Castano VG, Natarajan K, Waldman GJ, Argenziano M, Ottman R, Hripcsak G, Choi H, Youngerman BE. Patient characteristics and antiseizure medication pathways in newly diagnosed epilepsy: Feasibility and pilot results using the common data model in a single-center electronic medical record database. Epilepsy Behav 2022; 129:108630. [PMID: 35276502 DOI: 10.1016/j.yebeh.2022.108630] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/28/2022] [Accepted: 02/14/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Efforts to characterize variability in epilepsy treatment pathways are limited by the large number of possible antiseizure medication (ASM) regimens and sequences, heterogeneity of patients, and challenges of measuring confounding variables and outcomes across institutions. The Observational Health Data Science and Informatics (OHDSI) collaborative is an international data network representing over 1 billion patient records using common data standards. However, few studies have applied OHDSI's Common Data Model (CDM) to the population with epilepsy and none have validated relevant concepts. The goals of this study were to demonstrate the feasibility of characterizing adult patients with epilepsy and ASM treatment pathways using the CDM in an electronic health record (EHR)-derived database. METHODS We validated a phenotype algorithm for epilepsy in adults using the CDM in an EHR-derived database (2001-2020) against source records and a prospectively maintained database of patients with confirmed epilepsy. We obtained the frequency of all antecedent conditions and procedures for patients meeting the epilepsy phenotype criteria and characterized ASM exposure sequences over time and by age and sex. RESULTS The phenotype algorithm identified epilepsy with 73.0-85.0% positive predictive value and 86.3% sensitivity. Many patients had neurologic conditions and diagnoses antecedent to meeting epilepsy criteria. Levetiracetam incrementally replaced phenytoin as the most common first-line agent, but significant heterogeneity remained, particularly in second-line and subsequent agents. Drug sequences included up to 8 unique ingredients and a total of 1,235 unique pathways were observed. CONCLUSIONS Despite the availability of additional ASMs in the last 2 decades and accumulated guidelines and evidence, ASM use varies significantly in practice, particularly for second-line and subsequent agents. Multi-center OHDSI studies have the potential to better characterize the full extent of variability and support observational comparative effectiveness research, but additional work is needed to validate covariates and outcomes.
Collapse
Affiliation(s)
- Matthew Spotnitz
- Department of Biomedical Informatics, Columbia University Irving Medical Center, United States
| | - Anna Ostropolets
- Department of Biomedical Informatics, Columbia University Irving Medical Center, United States
| | - Victor G Castano
- Department of Neurological Surgery, Columbia University Irving Medical Center, United States
| | - Karthik Natarajan
- Department of Biomedical Informatics, Columbia University Irving Medical Center, United States
| | - Genna J Waldman
- Department of Neurology, Columbia University Irving Medical Center, United States
| | - Michael Argenziano
- Department of Neurological Surgery, Columbia University Irving Medical Center, United States
| | - Ruth Ottman
- Department of Neurology, Columbia University Irving Medical Center, United States; The Gertrude H. Sergievsky Center, Columbia University Vagelos College of Physicians and Surgeons, United States; Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, United States; Division of Translational Epidemiology, New York State Psychiatric Institute, United States
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University Irving Medical Center, United States
| | - Hyunmi Choi
- Department of Neurology, Columbia University Irving Medical Center, United States
| | - Brett E Youngerman
- Department of Neurological Surgery, Columbia University Irving Medical Center, United States.
| |
Collapse
|
30
|
Terman SW, Youngerman BE, Choi H, Burke JF. Antiseizure medication treatment pathways in US Medicare beneficiaries with newly treated epilepsy. Epilepsia 2022; 63:1571-1579. [PMID: 35294775 PMCID: PMC9314094 DOI: 10.1111/epi.17226] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/11/2022] [Accepted: 03/14/2022] [Indexed: 12/01/2022]
Abstract
Objective This study was undertaken to characterize antiseizure medication (ASM) treatment pathways in Medicare beneficiaries with newly treated epilepsy. Methods This was a retrospective cohort study using Medicare claims. Medicare is the United States' federal health insurance program for people aged 65 years and older plus younger people with disabilities or end‐stage renal disease. We included beneficiaries with newly treated epilepsy (International Classification of Diseases codes for epilepsy/convulsions 2014–2017, no ASM in the previous 2 years). We displayed the sequence of ASM fills using sunburst plots overall, then stratified by mood disorder, age, and neurologist prescriber. We tabulated drug costs for each pathway. Results We included 21 458 beneficiaries. Levetiracetam comprised the greatest number of pill days (56%), followed by gabapentin (11%) and valproate (8%). There were 22 288 unique treatment pathways. The most common pathways were levetiracetam monotherapy (43%), gabapentin monotherapy (10%), and valproate monotherapy (5%). Gabapentin was the most common second‐ and third‐line ASM. Whereas only 2% of pathways involved first‐line lacosamide, those pathways accounted for 19% of cost. Gabapentin and valproate use was increased and levetiracetam use was decreased in beneficiaries with mood disorders compared to beneficiaries without mood disorders. Levetiracetam use was increased and gabapentin, valproate, lamotrigine, and topiramate use was decreased in beneficiaries aged >65 years compared with those aged 65 years or less. Lamotrigine, levetiracetam, and lacosamide use was increased and gabapentin use was decreased in beneficiaries whose initial prescriber was a neurologist compared to those whose prescriber was not a neurologist. Significance Levetiracetam monotherapy was the most common pathway, although substantial heterogeneity existed. Lacosamide accounted for a small percentage of ASMs but a disproportionately large share of cost. Neurologists were more likely to prescribe lamotrigine compared with nonneurologists, and lamotrigine was prescribed far less frequently than may be endorsed by guidelines. Future work may explore patient‐ and physician‐driven factors underlying ASM choices.
Collapse
Affiliation(s)
- Samuel W Terman
- University of Michigan, Department of Neurology, Ann Arbor, MI, USA
| | - Brett E Youngerman
- Columbia University Irving Medical Center, Department of Neurosurgery, New York, New York, USA
| | - Hyunmi Choi
- Columbia University Irving Medical Center, Department of Neurology, New York, New York, USA
| | - James F Burke
- the Ohio State University, Department of Neurology, Columbus, OH, USA
| |
Collapse
|
31
|
Auerbach DS, Muniz CF. Cardiac Safety of Lamotrigine: Still Awaiting a Verdict. Neurology 2022; 98:697-698. [PMID: 35260441 DOI: 10.1212/wnl.0000000000200189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- David S Auerbach
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210
| | - Carlos F Muniz
- Department of Neurology, SUNY Upstate Medical University, Syracuse, NY 13210
| |
Collapse
|
32
|
Eslicarbazepine Acetate as Adjunctive Therapy for Primary Generalized Tonic-Clonic Seizures in Adults: A Prospective Observational Study. CNS Drugs 2022; 36:1113-1119. [PMID: 36178588 PMCID: PMC9550753 DOI: 10.1007/s40263-022-00954-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Eslicarbazepine acetate (ESL), a novel sodium channel blocker, is approved for mono and adjunctive treatment of partial epileptic seizures with or without secondary generalization. Its efficacy in primary generalized seizures has not yet been evaluated. OBJECTIVE To evaluate the efficacy and safety of ESL in primary generalized tonic-clonic seizures (PGTCS) in an observational study. METHODS The data were collected from a prospective population-based register. Effectiveness was measured as relative reduction in standardized seizure frequency (SSF), responder rate (≥ 50% reduction in SSF), and seizure freedom rate at 6 and 12 months after initiation of ESL. Safety and tolerability were evaluated using patients' diaries. RESULTS Fifty-six adult patients with PGTCS were treated with ESL as adjunctive therapy. Of these, 30.4% (n = 17) had myoclonic seizures in addition to PGTCS. The retention rate after 12 months was 80.4% (n = 45). After initiating ESL therapy, reduction in SSF for PGTCS on ESL was 56.0% after 6 months and 56.9% after 12 months (p < 0.01), whereas myoclonic seizures did not show any significant improvement in frequency. The responder rate for PGTCS was 64.3% after 6 months and 66.1% after 12 months, and seizure freedom was achieved in 32.1% and 35.7%, respectively. Forty-three patients (73.2%) reported no side effects. Among the reported side effects of ESL therapy, headache (7.1%), dizziness (8.9%), tiredness (7.1%), nausea (5.4%), and hyponatremia (5.4%) were the most prevalent. CONCLUSIONS Our data suggest that ESL may provide additional benefits in the treatment of patients with PGTCS and motivate randomized controlled trials in this indication.
Collapse
|
33
|
Eye disorders associated with newer antiepileptic drugs: A real-world disproportionality analysis of FDA adverse event reporting system. Seizure 2022; 96:66-73. [DOI: 10.1016/j.seizure.2022.01.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 01/16/2022] [Accepted: 01/17/2022] [Indexed: 01/08/2023] Open
|
34
|
Rathore C, Patel K, Satishchandra P. Current concepts in the management of idiopathic generalized epilepsies. Ann Indian Acad Neurol 2022; 25:35-42. [PMID: 35342251 PMCID: PMC8954322 DOI: 10.4103/aian.aian_888_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 10/30/2021] [Accepted: 11/05/2021] [Indexed: 11/15/2022] Open
Abstract
Idiopathic generalized epilepsies (IGEs) are a group of epilepsies characterized by an underlying genetic predisposition and a good response to antiseizure medicines (ASMs) in the majority of the patients. Of the various broad-spectrum ASMs, valproate is the most effective medicine for the control of seizures in IGEs. However, with the availability of many newer ASMs and evidence showing the high teratogenic potential of valproate, the choice of ASMs for IGEs has become increasingly difficult, especially in women of the child-bearing age group. In this article, we review the current evidence regarding the efficacy and safety of various ASMs in patients with IGEs and provide practical guidelines for choosing appropriate ASMs in various subgroups of patients with IGEs.
Collapse
|
35
|
Rinaldi VE, Di Cara G, Mencaroni E, Verrotti A. Therapeutic Options for Childhood Absence Epilepsy. Pediatr Rep 2021; 13:658-667. [PMID: 34941639 PMCID: PMC8705546 DOI: 10.3390/pediatric13040078] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 12/02/2021] [Accepted: 12/09/2021] [Indexed: 11/30/2022] Open
Abstract
Childhood absence epilepsy (CAE) is a common pediatric generalized epileptic syndrome. Although it is traditionally considered as a benign self-limited condition, the apparent benign nature of this syndrome has been revaluated in recent years. This is mainly due to the increasing evidence that children with CAE can present invalidating neuropsychological comorbidities that will affect them up to adulthood. Moreover, a percentage of affected children can develop drug-resistant forms of CAE. The purpose of this review is to summarize the most recent studies and new concepts concerning CAE treatment, in particular concerning drug-resistant forms of CAE. A Pubmed search was undertaken to identify all articles concerning management and treatment of CAE, including articles written between 1979 and 2021. Traditional anticonvulsant therapy of CAE that is still in use is based on three antiepileptic drugs: ethosuximide which is the drug of choice, followed by valproic acid and lamotrigine. In the case of first line treatment failure, after two monotherapies it is usual to start a bi-therapy. In the case of absence seizures that are refractory to traditional treatment, other antiepileptic drugs may be introduced such as levetiracetam, topiramate and zonisamide.
Collapse
Affiliation(s)
| | - Giuseppe Di Cara
- Pediatric Unit, Department of Medicine and Surgery, University of Perugia, 06156 Perugia, Italy; (G.D.C.); (E.M.); (A.V.)
| | - Elisabetta Mencaroni
- Pediatric Unit, Department of Medicine and Surgery, University of Perugia, 06156 Perugia, Italy; (G.D.C.); (E.M.); (A.V.)
| | - Alberto Verrotti
- Pediatric Unit, Department of Medicine and Surgery, University of Perugia, 06156 Perugia, Italy; (G.D.C.); (E.M.); (A.V.)
| |
Collapse
|
36
|
Abdennadher M, Saxena A, Pavlova MK. Evaluation and Management of First-Time Seizure in Adults. Semin Neurol 2021; 41:477-482. [PMID: 34619775 DOI: 10.1055/s-0041-1735143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
First seizures are often perceived as devastating events by patients and their families due to the fear of having a life-long disease. One in 10 people experiences one or more seizures during their lifetime, while 1 in 26 people develops epilepsy. Acute symptomatic seizures are often related to a provoking factor or an acute brain insult and typically do not recur. Careful history and clinical examination should guide clinicians' management plans. Electroencephalography and brain imaging, preferably with epilepsy-specific magnetic resonance imaging, may help characterize both etiology and risk of seizure recurrence. Antiepileptic drugs should be initiated in patients with newly diagnosed epilepsy. In patients without an epilepsy diagnosis, the decision to prescribe drugs depends on individual risk factors for seizure recurrence and possible complications from seizures, which should be discussed with the patient. Counseling about driving and lifestyle modifications should be provided early, often at the first seizure encounter.
Collapse
Affiliation(s)
- Myriam Abdennadher
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Aneeta Saxena
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Milena K Pavlova
- Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
37
|
Hakami T. Efficacy and tolerability of antiseizure drugs. Ther Adv Neurol Disord 2021; 14:17562864211037430. [PMID: 34603506 PMCID: PMC8481725 DOI: 10.1177/17562864211037430] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 07/19/2021] [Indexed: 12/17/2022] Open
Abstract
Drug-resistant epilepsy occurs in 25-30% of patients. Furthermore, treatment with a first-generation antiseizure drug (ASD) fails in 30-40% of individuals because of their intolerable adverse effects. Over the past three decades, 20 newer- (second- and third-)generation ASDs with unique mechanisms of action and pharmacokinetic profiles have been introduced into clinical practice. This advent has expanded the therapeutic armamentarium of epilepsy and broadens the choices of ASDs to match the individual patient's characteristics. In recent years, research has been focused on defining the ASD of choice for different seizure types. In 2017, the International League Against Epilepsy published a new classification for seizure types and epilepsy syndrome. This classification has been of paramount importance to accurately classify the patient's seizure type(s) and prescribe the ASD that is appropriate. A year later, the American Academy of Neurology published a new guideline for ASD selection in adult and pediatric patients with new-onset and treatment-resistant epilepsy. The guideline primarily relied on studies that compare the first-generation and second-generation ASDs, with limited data for the efficacy of third-generation drugs. While researchers have been called for investigating those drugs in future research, epilepsy specialists may wish to share their personal experiences to support the treatment guidelines. Given the rapid advances in the development of ASDs in recent years and the continuous updates in definitions, classifications, and treatment guidelines for seizure types and epilepsy syndromes, this review aims to present a complete overview of the current state of the literature about the efficacy and tolerability of ASDs and provide guidance to clinicians about selecting appropriate ASDs for initial treatment of epilepsy according to different seizure types and epilepsy syndromes based on the current literature and recent US and UK practical guidelines.
Collapse
Affiliation(s)
- Tahir Hakami
- The Faculty of Medicine, Jazan University, P.O. Box 114, Jazan 45142, Saudi Arabia
| |
Collapse
|
38
|
Hakami T. Neuropharmacology of Antiseizure Drugs. Neuropsychopharmacol Rep 2021; 41:336-351. [PMID: 34296824 PMCID: PMC8411307 DOI: 10.1002/npr2.12196] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/01/2021] [Accepted: 07/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Antiseizure drugs (ASDs) are the primary therapy for epilepsy, with more than 20 drugs introduced into clinical practice to date. These drugs are typically grouped by their mechanisms of action and therapeutic spectrum. This article aims to educate non-neurologists and medical students about the new frontiers in the pharmacology of ASDs and presents the current state of the literature on the efficacy and tolerability of these agents. METHODS Randomized controlled trials, observational studies, and evidence-based meta-analyses of ASD efficacy and tolerability as initial monotherapy for epileptic seizures and syndromes were identified in PubMed, EMBASE, the Cochrane Library, and Elsevier Clinical Pharmacology. RESULTS The choice of ASD varies primarily according to the seizure type. Practical guidelines for ASD selection in patients with new-onset and drug-resistant epilepsy were recently published. The guidelines have shown that the newer-generation drugs, which have unique mechanistic and pharmacokinetic properties, are better tolerated but have similar efficacy compared with the older drugs. Several ASDs are effective as first-line monotherapy in focal seizures, including lamotrigine, carbamazepine, phenytoin, levetiracetam, and zonisamide. Valproate remains the first-line drug for many patients with generalized and unclassified epilepsies. However, valproate should be avoided, if possible, in women of childbearing potential because of teratogenicity. Toxicity profile precludes several drugs from use as first-line treatment, for example, vigabatrin, felbamate, and rufinamide. CONCLUSIONS Antiseizure drugs have different pharmacologic profiles that should be considered when selecting and prescribing these agents for epilepsy. These include pharmacokinetic properties, propensity for drug-drug interactions, and adverse effects.
Collapse
Affiliation(s)
- Tahir Hakami
- The Faculty of MedicineJazan UniversityJazanSaudi Arabia
| |
Collapse
|
39
|
Zaccara G, Lattanzi S, Brigo F. Which treatment strategy in patients with epilepsy with focal seizures uncontrolled by the first anti-seizure medication? Epilepsy Behav 2021; 121:108031. [PMID: 33992932 DOI: 10.1016/j.yebeh.2021.108031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 04/27/2021] [Accepted: 04/27/2021] [Indexed: 10/21/2022]
Abstract
There is no definite proven or accepted strategy in the management of patients with focal epilepsy uncontrolled by the first anti-seizure medication (ASM). Clinical studies failed to find a significant difference in efficacy or tolerability between alternative monotherapy and/or adjunctive therapy in these patients. A second ASM is often added, the efficacy of the combination is assessed, and the dose of the first drug can be gradually reduced and withdrawn. If seizures recur, the effective combination therapy can be reinstated. In this review, we discussed experimental and clinical data about the efficacy and tolerability of the most frequently used combinations of ASMs. Animal studies suggested that the most favorable combinations are those between ASMs with different or multiple mechanisms of action, whereas combining drugs with similar pharmacodynamic properties is often associated with additive or infra-additive efficacy and additive or synergistic toxicity. Clinical studies have shown that levetiracetam (LEV) can be favorably combined with the sodium channel blockers (SCBs) lacosamide (LCM) and lamotrigine (LTG). Lamotrigine is particularly effective when associated with valproate (VPA) and possibly with LEV and topiramate (TPM). Carbamazepine (CBZ) has negative pharmacokinetic interactions with several ASMs and should not be combined with other SCBs; it could be effectively and safely combined with gabapentin (GBP) and LEV. Valproic acid has enzyme inhibiting properties and can be cautiously used with SCBs; its combination with TPM or zonisamide (ZNS) may be associated with higher toxicity.
Collapse
Affiliation(s)
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| |
Collapse
|
40
|
Chaijamorn W, Charoensareerat T, Rungkitwattanakul D, Phunpon S, Sathienluckana T, Srisawat N, Pattharachayakul S. Levetiracetam dosing in patients receiving continuous renal replacement therapy. Epilepsia 2021; 62:2151-2158. [PMID: 34247386 DOI: 10.1111/epi.16971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 06/02/2021] [Accepted: 06/04/2021] [Indexed: 01/21/2023]
Abstract
OBJECTIVE The study was aimed to define appropriate levetiracetam dosing regimens from available published pharmacokinetics (PK) studies in critically ill patients with and without cirrhosis receiving continuous renal replacement therapy (CRRT) via Monte Carlo simulation (MCS). METHODS Mathematical pharmacokinetic models were developed using published demographic and PK data in adult critically ill patients with known variability and correlations between PK parameters. CRRT modalities (continuous venovenous hemofiltration and continuous venovenous hemodialysis) with different effluent rates were modeled. Levetiracetam regimens from available clinical resources were evaluated on the probability of target attainment (PTA) using pharmacodynamics (PD) target of the trough concentrations and area under the time-concentration curve within a range of 6-20 mg/L and 222-666 mg × hour/L for the initial 72 hours of therapy, respectively. Optimal regimens were defined from regimens that yielded the highest PTA. Each regimen was tested in a group of different 10,000 virtual patients. RESULTS Our results showed the optimal levetiracetam dosing regimen of 750-1000 mg every 12 hours is recommended for adult patients receiving both CRRT modalities with two different effluent rates of 25 and 35 mL/kg/h. Child-Pugh class C cirrhotic patients undergoing CRRT required lower dosing regimens of 500-750 mg every 12 ours due to smaller non-renal clearance. Of interest, some of literature-based dosing regimens were not able to attain the PK and PD targets. SIGNIFICANCE Volume of distribution, non-renal clearance, CRRT clearance, and body weight were significantly correlated with the PTA targets. Dosing adaptation in this vulnerable population should be concerned. Clinical validation of our finding is absolutely needed.
Collapse
Affiliation(s)
| | | | - Dhakrit Rungkitwattanakul
- Department of Clinical and Administrative Pharmacy Sciences, College of Pharmacy, Howard University, Washington, DC, USA
| | | | | | - Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Academic of Science, Royal Society of Thailand, Bangkok, Thailand.,Tropical Medicine Cluster, Chulalongkorn University, Bangkok, Thailand.,Department of Critical Care Medicine, Center for Critical Care Nephrology, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sutthiporn Pattharachayakul
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Songkhla, Thailand
| |
Collapse
|
41
|
Riviello JJ, Erklauer J. Evidence-Based Protocols in Child Neurology. Neurol Clin 2021; 39:883-895. [PMID: 34215392 DOI: 10.1016/j.ncl.2021.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Medical care has become more complex as the scientific method has expanded medical knowledge. Medicine is also now practiced across different medical systems of varying complexity, and creating standard treatment guidelines is one way of establishing uniform treatment across these systems. The creation of guidelines ensures the delivery of quality medical care and improved patient outcomes. Evidence-based medicine is the application of scientific research to produce these treatment guidelines. This article shall focus on the current treatment guidelines used for inpatient pediatric neurology.
Collapse
Affiliation(s)
- James J Riviello
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1250, Houston, TX 77030, USA.
| | - Jennifer Erklauer
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1250, Houston, TX 77030, USA; Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1250, Houston, TX 77030, USA
| |
Collapse
|
42
|
Smegal LF, Sebold AJ, Hammill AM, Juhász C, Lo WD, Miles DK, Wilfong AA, Levin AV, Fisher B, Ball KL, Pinto AL, Comi AM. Multicenter Research Data of Epilepsy Management in Patients With Sturge-Weber Syndrome. Pediatr Neurol 2021; 119:3-10. [PMID: 33813331 PMCID: PMC8162684 DOI: 10.1016/j.pediatrneurol.2021.02.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 02/10/2021] [Accepted: 02/14/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Epilepsy in typical Sturge-Weber syndrome (SWS) is common, and many questions remain regarding the treatment outcomes. We analyzed a large multicenter database with focus on neurological drug treatment in different demographic and SWS characteristic groups. METHODS A total of 268 patients with brain involvement and a history of seizures were selected from a research data registry generated from a multicenter cross-sectional questionnaire. We examined associations between medication use and binary variables such as sex, ethnicity, and brain, skin, and eye involvement laterality. We analyzed group differences in mean number of antiseizure medications and age at diagnosis, enrollment, and seizure onset and examined differences in median SWS neurological scores in groups of interest. RESULTS The most frequently used medications were levetiracetam (48.1%), low-dose aspirin (44.8%), oxcarbazepine (39.9%), and phenobarbital (14.9%). Lamotrigine was more frequently used in adults than in children (P = 0.001). History of neurosurgery was associated with no current antiseizure medication use (P = 0.001), whereas bilateral brain involvement and family history of seizures were associated with using a higher number of antiseizure medications (P = 0.002, P = 0.027, respectively). Subjects with bilateral brain involvement and early seizure onset were associated with using a higher number of antiseizure medications (P = 0.002) and phenobarbital use (0.003). CONCLUSIONS Levetiracetam, low-dose aspirin, and oxcarbazepine were the most frequently used medications. More severely affected patients were frequently on a greater number of antiseizure medications. Surgery for epilepsy was associated with the ability to discontinue antiseizure medication. Longitudinal studies are needed to further investigate medication use in patients with SWS.
Collapse
Affiliation(s)
- Lindsay F. Smegal
- Department of Neurology, Hugo Moser Kennedy Krieger Research Institute, Baltimore, Maryland
| | - Alison J. Sebold
- Department of Neurology, Hugo Moser Kennedy Krieger Research Institute, Baltimore, Maryland
| | - Adrienne M. Hammill
- Division of Hematology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Csaba Juhász
- Departments of Pediatrics, Neurology, and Neurosurgery, Wayne State University School of Medicine, Children’s Hospital of Michigan, Detroit, Michigan
| | - Warren D. Lo
- Neurology, Nationwide Children’s Hospital, Columbus, Ohio
| | - Daniel K. Miles
- Department of Neurology, Pediatric Epilepsy, New York University Langone Health, New York, New York
| | - Angus A. Wilfong
- Neurology, Barrow Neurological Institute, Phoenix Children’s Hospital, Phoenix, Arizona
| | - Alex V. Levin
- Pediatric Ophthalmology and Ocular Genetics, Flaum Eye Institute, Golisano Children’s Hospital, University of Rochester, Rochester, New York
| | | | | | - Anna L. Pinto
- Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Anne M. Comi
- Department of Neurology, Hugo Moser Kennedy Krieger Research Institute, Baltimore, Maryland,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland,Department of Pediatrics, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland,Communications should be addressed to: Dr. Comi; Department of Neurology; Hugo Moser Kennedy Krieger Research Institute; Rm 553, Kennedy Krieger Outpatient Bldg, 801 North Broadway; Baltimore, MD 21205. (A.M. Comi)
| | | |
Collapse
|
43
|
Mehta D, Davis M, Epstein AJ, Wensel B, Grinnell T, Williams GR. Comparative Economic Outcomes in Patients with Focal Seizure Initiating First-Line Eslicarbazepine Acetate Monotherapy versus Generic Antiseizure Drugs. CLINICOECONOMICS AND OUTCOMES RESEARCH 2021; 13:251-261. [PMID: 33907433 PMCID: PMC8064618 DOI: 10.2147/ceor.s303079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/12/2021] [Indexed: 01/12/2023] Open
Abstract
Objective To examine the association between initiating first-line (1L) monotherapy with eslicarbazepine acetate (ESL) vs a generic antiseizure drug (ASD) and healthcare resource utilization (HCRU) and charges in adults with treated focal seizures (FS). Methods This was a retrospective analysis of Symphony Health’s Integrated Dataverse® open-source claims data. Two cohorts were identified as having initiated 1L monotherapy with ESL or literature-defined generic ASDs. Linear regression models with person fixed effects and inverse probability treatment weights assessed the relative additional changes in HCRU and charges among patients who received ESL compared to generic ASD. Results A total of 250 and 43,220 patients initiated ESL (48.3 years; 57.2% female) or a generic ASD (54.5 years; 58.1% female), respectively. Compared to patients initiating a generic ASD, patients treated with ESL had additional reductions of 11.8 percentage points in the likelihood of any all-cause outpatient visits (P<0.001), 7.4 percentage points in the likelihood of any emergency department (ED) visits (P=0.013), and 22.7 percentage points in the likelihood of any FS-related outpatient visits (P<0.001). Patients initiating ESL had greater reductions in mean charges for all-cause medical ($2620; P=0.002), outpatient ($1995; P=0.005), and non-FS-related medical ($2708; P<0.001) services. Patients initiating ESL had greater relative increases in mean total prescription ($1368; P<0.001) and ASD-related prescription ($1636; P<0.001) charges, but greater relative reductions in non-ASD prescription ($269; P=0.032) charges. The increases in prescription charges were of a lower magnitude than the decreases in medical charges. Conclusion Initiation of ESL as 1L monotherapy was associated with statistically significantly greater reductions in any use of several all-cause and FS-related services, number of visits, and charges compared to initiation of a generic ASD as 1L monotherapy in patients with FS. Initiation of a generic ASD as 1L monotherapy was associated with significantly smaller increases in total prescription charges and ASD-related prescription charges.
Collapse
Affiliation(s)
| | | | | | - Brian Wensel
- Sunovion Pharmaceuticals Inc., Marlborough, MA, USA
| | - Todd Grinnell
- Medical Affairs, Sunovion Pharmaceuticals Inc., Marlborough, MA, USA
| | | |
Collapse
|
44
|
Cutillo G, Tolba H, Hirsch LJ. Anti-seizure medications and efficacy against focal to bilateral tonic-clonic seizures: A systematic review with relevance for SUDEP prevention. Epilepsy Behav 2021; 117:107815. [PMID: 33640562 DOI: 10.1016/j.yebeh.2021.107815] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/20/2021] [Accepted: 01/20/2021] [Indexed: 11/17/2022]
Abstract
We conducted a systematic review of anti-seizure medications (ASMs) and their efficacy for the control of focal to bilateral tonic-clonic seizures (FBTCS). FBTCS, especially when nocturnal, are recognized as one of the major risk factors for Sudden Unexpected Death in Epilepsy (SUDEP). We searched different online databases for all the randomized, double-blinded, and placebo-controlled clinical trials of ASMs that were FDA-approved after 1990 and that reported specifically on the reduction in FBTCS; when possible, this was compared to reduction in focal impaired awareness (FIA) seizures. The ASMs that yielded the most data (3 or more studies) were topiramate (TPM), followed by tiagabine (TGB), brivaracetam (BRV), and lamotrigine (LTG). TPM trials showed a reduction in FBTCS of 44.8% to 100% (4.5-99% over placebo); TGB 21.8% to 46.7% (21.8-61% over placebo); BRV 33.9% to 82.1% (11.6-57.4% over placebo); and LTG 55.2% (20.3-52% over placebo). Promising results, but with data from only one or two studies, were seen with cenobamate (18-59% efficacy above placebo), lacosamide (45.1-78.7%), levetiracetam (40.1-60.3%), oxcarbazepine (58.5-81.5%), and gabapentin (50-53.8%). Higher responses were often seen at higher doses, including at doses above those currently approved by the FDA. Results specific to nocturnal FBTCS were never reported for any ASM. Moreover, complete freedom from FBTCS specifically was very rarely reported, despite its relevance for SUDEP prevention. In conclusion, there are few data specifically comparing the efficacy of ASMs for prevention of FBTCS despite the known strong association of BTCS with SUDEP. This review was our attempt at filling a gap in the literature and calling for universal reporting of data specific to BTC seizure reduction in all future studies, preferably including specific reporting on nocturnal BTCS. This will help enable rational ASM selection to minimize BTC seizures and thereby decrease the risk of SUDEP.
Collapse
Affiliation(s)
- Gianni Cutillo
- Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, MA 02215, USA
| | - Hatem Tolba
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA; Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA.
| |
Collapse
|
45
|
Wheless JW. A critical evaluation of midazolam nasal spray for the treatment of patients with seizure clusters. Expert Rev Neurother 2021; 21:1195-1205. [PMID: 33593228 DOI: 10.1080/14737175.2021.1890033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Patients with epilepsy may experience seizure clusters (SCs), which are considered a medical emergency requiring immediate treatment. Besides seizures and seizure-related injuries, patients with SCs experience impaired quality of life and have a greater need for healthcare resources. Midazolam nasal spray (MDZ-NS) was approved by the United States Food and Drug Administration (FDA) for the treatment of SCs in 2019, and was the first FDA-approved nasally administered formulation for treating SCs.Areas covered: This article provides a critical evaluation of MDZ-NS for the treatment of patients with SCs. It covers the chemistry, pharmacodynamic and pharmacokinetic properties of MDZ-NS, and safety, tolerability, and efficacy data from phase I and phase III trials. SC treatment guidelines in different countries and for alternative therapies are also discussed.Expert opinion: Midazolam is a well-established drug that is familiar to physicians. The newer MDZ-NS formulation offers the benefits of intranasal administration, which allows for outpatient treatment by caregivers and other non-healthcare professionals when an SC occurs, and may be particularly meaningful to patients with limited treatment options because other routes of administration are unsuitable. MDZ-NS is effective and patients are known to return to baseline alertness and psychomotor function within 240 minutes after administration.
Collapse
Affiliation(s)
- James W Wheless
- Le Bonheur Comprehensive Epilepsy Program & Neuroscience Institute, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| |
Collapse
|
46
|
Santhosh AP, Kumar Goyal M, Modi M, Kharbanda PS, Ahuja CK, Tandyala N, Prabhat N, Singh R, Mehta S, Vinay Mahesh K. Carbamazepine versus levetiracetam in epilepsy due to neurocysticercosis. Acta Neurol Scand 2021; 143:242-247. [PMID: 33006755 DOI: 10.1111/ane.13355] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 09/03/2020] [Accepted: 09/24/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The choice of antiepileptic drug (AED) in newly diagnosed neurocysticercosis (NCC) patients with epilepsy continues to be arbitrary. We compared efficacy and side effect profile of levetiracetam (LEV) and carbamazepine (CBZ) for the treatment of seizures in newly diagnosed patients with NCC. PATIENTS AND METHODS This was an open-labeled randomized comparative monotherapy study including newly diagnosed drug naïve patients of NCC (n = 99) presenting with seizures who were randomized in 1:1 ratio using computed generated numbers. All patients were followed up for at least six months after start of treatment. The primary outcome measure was seizure control over six months following start of AEDs. RESULTS Fifteen (15.2%) patients [CBZ- 4(8.2%); LEV- 11(22%)] developed recurrence of seizures. A trend (p = 0.09) was found toward better control of seizures in CBZ compared to LEV. Two (4%) patients in LEV group and 17 (34.6%) patients in CBZ group developed drug-related minor side effects (p < 0.0001). Three patients in CBZ group needed discontinuation of therapy due to skin rash. Eleven patients who relapsed while on LEV did not have any recurrence of seizures after switching over to CBZ. Out of 3 patients who relapsed while receiving CBZ and were changed to LEV, two developed seizures during follow-up. CONCLUSION CBZ and LEV could be used as alternatives in newly diagnosed patients of NCC at the behest of minor side effects in the CBZ group.
Collapse
Affiliation(s)
- Akhil P. Santhosh
- Department of Internal Medicine Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Manoj Kumar Goyal
- Department of Neurology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Manish Modi
- Department of Neurology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Parampreet S. Kharbanda
- Department of Neurology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Chirag K. Ahuja
- Department of Radiodiagnosis and Imaging Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Naresh Tandyala
- Department of Neurology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Nandita Prabhat
- Department of Neurology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Rajveer Singh
- Department of Neurology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Sahil Mehta
- Department of Neurology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Karthik Vinay Mahesh
- Department of Neurology Postgraduate Institute of Medical Education and Research Chandigarh India
| |
Collapse
|
47
|
Alsfouk BAA, Brodie MJ, Walters M, Kwan P, Chen Z. Tolerability of Antiseizure Medications in Individuals With Newly Diagnosed Epilepsy. JAMA Neurol 2021; 77:574-581. [PMID: 32091535 DOI: 10.1001/jamaneurol.2020.0032] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Tolerability is a key determinant of the effectiveness of epilepsy treatment. It is important to evaluate whether the overall tolerability has improved. Objective To identify factors associated with poor tolerability of antiseizure medications (ASMs) and examine temporal changes in tolerability. Design, Setting, and Participants This was a longitudinal cohort study at a specialist clinic in Glasgow, Scotland. Patients with newly diagnosed and treated epilepsy between July 1982 and October 2012 were included from 2282 eligible individuals. They were followed up until April 2016 or death. Data analysis was completed in August 2019. Exposures Antiseizure medications. Main Outcomes and Measures Univariable and multivariable survival analyses were performed to examine associations between potential risk factors and development of intolerable adverse effects (AEs). Intolerable AE rates of the ASMs as the initial monotherapy were compared between 3 epochs (July 1982-June 1992, July 1992-June 2002, and July 2002-April 2016). Results Of 1795 patients, 969 (54.0%) were male, and the median (interquartile range) age was 33 (21-50) years. A total of 3241 ASMs were prescribed during the period, of which 504 (15.6%) were discontinued within 6 months owing to intolerable AEs. Children younger than 18 years had lower intolerable AE rates than adults (vs aged 18-64 years: adjusted hazard ratio [aHR], 1.58; 95% CI, 1.07-2.32; vs aged ≥65 years: aHR, 1.90; 95% CI, 1.19-3.02) while female individuals (aHR, 1.60; 95% CI, 1.30-1.96) and those who had more than 5 pretreatment seizures (aHR, 1.24; 95% CI, 1.03-1.49) were associated with having higher risk. For each ASM trial, the risk of intolerable AEs increased with the number of previous drug withdrawals due to AEs (aHR, 1.18; 95% CI, 1.09-1.28) and the number of concomitant ASMs (aHR, 1.31; 95% CI, 1.04-1.64). The proportion of second-generation ASMs prescribed as the initial monotherapy increased from 22.3% (33 of 148) in the first epoch to 68.7% (645 of 939) in the last (P < .001). Although differences in intolerable AE rates and types of AEs were found between the ASMs, there was no difference in the overall intolerable AEs rates to the initial monotherapy across the 3 epochs (first: 10.1% [15 of 148]; second: 13.8% [98 of 708]; third: 14.0% [131 of 939]; P = .41). Conclusions and Relevance In this cohort study, the increased use of the second-generation ASMs had not improved overall treatment tolerability. Greater effort to improve tolerability in ASM development is needed.
Collapse
Affiliation(s)
- Bshra Ali A Alsfouk
- University of Glasgow, Glasgow, Scotland.,College of Pharmacy, Department of Pharmaceutical Sciences, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Martin J Brodie
- University of Glasgow, Glasgow, Scotland.,Epilepsy Unit, Scottish Epilepsy Initiative, Glasgow, Scotland
| | | | - Patrick Kwan
- Central Clinical School, Department of Neuroscience, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Zhibin Chen
- Central Clinical School, Department of Neuroscience, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,School of Public Health and Preventive Medicine, Clinical Epidemiology, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
48
|
Jeon J, Oh J, Yu KS. A meta-analysis: efficacy and safety of anti-epileptic drugs prescribed in Korea as monotherapy and adjunctive treatment for patients with focal epilepsy. Transl Clin Pharmacol 2021; 29:6-20. [PMID: 33854997 PMCID: PMC8020359 DOI: 10.12793/tcp.2021.29.e1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/16/2020] [Accepted: 12/28/2020] [Indexed: 01/08/2023] Open
Abstract
Focal epilepsy is the most common type of epilepsy in Korea, and anti-epileptic drugs (AEDs) are the main treatment option for patients. This study aimed to compare the efficacy and safety of AEDs for focal epilepsy through a meta-analysis. The AEDs prescribed in Korea as monotherapy and adjunctive treatment for patients with focal epilepsy were included for analysis. Relevant articles were searched for randomized clinical trials of AEDs and treatment outcomes were analyzed on the basis of the 50% responder rate, seizure-free rate, treatment withdrawal rate, and emergence rates of adverse events (AEs). The odds ratios (ORs) and their 95% confidence intervals (CI) of study outcome were calculated using combined data from multiple studies. A total of 47 studies were included in the meta-analysis. The seizure-free rate, treatment withdrawal rate, and AE rate were not significantly different among the AEDs recommended for monotherapy. Among the AEDs recommended for adjunctive treatment, topiramate and oxcarbazepine yielded the highest OR in comparison with placebo for each efficacy parameter: the 50% responder rate for topiramate = 6.42 (3.76–11.6) and the seizure-free rate for oxcarbazepine = 32.7 (6.05–899). The third-generation AEDs (brivaracetam and perampanel) yielded relatively better safety outcomes than other AEDs. In general, the 50% responder rate and treatment withdrawal rate tended to increase as the dose of the AEDs increased. The results from the current meta-analysis of the efficacy and safety data of various AEDs may provide insight into optimal pharmacotherapy for the treatment of focal epilepsy.
Collapse
Affiliation(s)
- JuYeun Jeon
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul 03080, Korea
| | - Jaeseong Oh
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul 03080, Korea
| | - Kyung-Sang Yu
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul 03080, Korea
| |
Collapse
|
49
|
Boon P, Ferrao Santos S, Jansen AC, Lagae L, Legros B, Weckhuysen S. Recommendations for the treatment of epilepsy in adult and pediatric patients in Belgium: 2020 update. Acta Neurol Belg 2021; 121:241-257. [PMID: 33048338 PMCID: PMC7937601 DOI: 10.1007/s13760-020-01488-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 08/26/2020] [Indexed: 12/31/2022]
Abstract
To guide health care professionals in Belgium in selecting the appropriate antiepileptic drugs (AEDs) for their epilepsy patients, a group of Belgian epilepsy experts developed recommendations for AED treatment in adults and children (initial recommendations in 2008, updated in 2012). As new drugs have become available, others have been withdrawn, new indications have been approved and recommendations for pregnant women have changed, a new update was pertinent. A group of Belgian epilepsy experts (partly overlapping with the group in charge of the 2008/2012 recommendations) evaluated the most recent international guidelines and relevant literature for their applicability to the Belgian situation (registration status, reimbursement, clinical practice) and updated the recommendations for initial monotherapy in adults and children and add-on treatment in adults. Recommendations for add-on treatment in children were also included (not covered in the 2008/2012 publications). Like the 2008/2012 publications, the current update also covers other important aspects related to the management of epilepsy, including the importance of early referral in drug-resistant epilepsy, pharmacokinetic properties and tolerability of AEDs, comorbidities, specific considerations in elderly and pregnant patients, generic substitution and the rapidly evolving field of precision medicine.
Collapse
Affiliation(s)
- Paul Boon
- Reference Center for Refractory Epilepsy, Department of Neurology, Ghent University Hospital, Ghent, Belgium.
| | | | - Anna C Jansen
- Pediatric Neurology Unit, Department of Pediatrics, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Lieven Lagae
- Reference Center for Refractory Epilepsy, Pediatric Neurology, Department of Development and Regeneration, University Hospitals Leuven, Leuven, Belgium
| | - Benjamin Legros
- Department of Neurology, Reference Center for the Treatment of Refractory Epilepsy, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Sarah Weckhuysen
- Department of Neurology, Antwerp University Hospital, Antwerp, Belgium
- VIB-Center for Molecular Neurology, University of Antwerp, Antwerp, Belgium
| |
Collapse
|
50
|
Abstract
PURPOSE OF REVIEW Nearly two dozen antiseizure medications (ASMs) with different mechanisms of action have been introduced over the past three decades with the aim of providing better efficacy or safety profile than the previous drugs. Several new ASMs with improvement on a classic drug family or have novel mechanisms of action have been recently approved for epilepsy. The present review explored recent studies or guidelines on new agents and discussed the potential impact of these novel treatments on epilepsy management and future directions of research. RECENT FINDINGS Long-term cohort studies showed that, collectively, the second-generation did not improve the overall prognosis of epilepsy. Individual monotherapy studies showed similar efficacy of second-generation (levetiracetam and zonisamide) and third-generation (eslicarbazepine acetate and lacosamide) ASMs compared to controlled-release carbamazepine for the treatment of focal epilepsy. However, there appears to be no evidence to support any second-generation or third-generation ASMs to be as efficacious as valproate monotherapy for generalized and unclassified epilepsies. Cannabidiol adjunctive treatments were found to be efficacious for Dravet syndrome and Lennox-Gastaut syndrome. Although most newer generation ASMs are less prone to drug-drug interactions, stiripentol and cannabidiol can elevate the plasma concentration of N-desmethylclobazam, the active metabolite of clobazam. Generally speaking, the second-generation ASMs have lower teratogenic risk than the older drugs but there is scant study on neurodevelopmental effect of third-generation ASMs. SUMMARY Although the newer generation ASMs may not have improved the overall seizure control they have advantages in terms of drug-drug interactions and teratogenicity, and thus offer valuable individualized options in the treatment of epilepsy.
Collapse
|