Juvenile myoclonic epilepsy: diagnosis, management and outcome

Cosmetic adverse effects of antiseizure medications; A systematic review

BACKGROUND

We systematically reviewed the existing literature on the cosmetic adverse effects of antiseizure medications (ASMs) in order to depict a clear picture of these unwanted side effects of ASMs with a particular attention to hair loss, hirsutism, acne, and gingival hyperplasia.

METHODS

This systematic review was prepared according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Scopus, MEDLINE, and Google Scholar from the inception to 25 March, 2021 were systematically searched. These key words (title/abstract) were used: "hair loss" OR "hirsutism" OR "acne" OR "gingival hyperplasia" AND "seizure" OR "epilepsy" OR "anriseizure" OR "antiepileptic". The exclusion criteria included: non-original studies, articles not in English, and animal studies.

RESULTS

The primary search yielded 3938 studies; 127 studies were related to the topic and were included in the current systematic review. The most robust evidence on cosmetic adverse effects of ASMs were related to phenytoin (causing gingival hyperplasia, hirsutism, and acne) and valproate (causing hair loss and hirsutism); however, many other ASMs were also implicated in causing these cosmetic adverse effects.

CONCLUSION

Antiseizure medications may be associated with various cosmetic adverse effects. Phenytoin and valproate are the most notorious ASMs in this regard; but, other ASMs have also been implicated in causing hair loss, hirsutism, acne, and gingival hyperplasia. Physicians should pay more attention to these significant adverse effects that may affect a patient's facial attractiveness, quality of life, and emotional state.

Lamotrigine and its applications in the treatment of epilepsy and other neurological and psychiatric disorders

Lamotrigine is a broad-spectrum antiepileptic drug, initially approved in 1994 for the adjunctive treatment of partial seizures in adults and for the generalized seizures of Lennox-Gastaut syndrome in pediatric (>2 years old) and adult populations. Its role in the treatment of bipolar disorder type I has also been well established. In addition, lamotrigine has been successfully used for the management of other neurological conditions such as migraines and neuropathic pain, and preliminary data show promising results. It has favorable pharmacokinetic properties and is generally well tolerated. The small risk of serious skin rash can be minimized with slow titration of the drug and dose adjustment with concomitant medications. Lamotrigine has demonstrated particular benefit in the treatment of women and elderly patients with epilepsy.

Predicting antiepileptic drug response in children with epilepsy

In clinical practice, after diagnosis and when treatment has begun, it is important to predict as soon as possible which children will become seizure-free and which are likely to develop medically intractable seizures. This article summarizes factors predicting seizure remission in childhood-onset epilepsy treated with antiepileptic drugs (AEDs). Sustained seizure remission can be expected in over 90% of idiopathic epilepsies of childhood and in neurologically normal children with epilepsy having infrequent seizures showing early remission after starting treatment with AEDs. Even in the presence of symptomatic etiology of epilepsy--focal seizures and syndromes; high seizure frequency prior to or during treatment; seizure clustering; and poor or delayed response to first adequate drug therapy--up to 60% of children with treated epilepsy are able to enter long-term remission. However, remission can be expected in only 30% or less of those with catastrophic epilepsies of childhood.

ILAE treatment guidelines: evidence-based analysis of antiepileptic drug efficacy and effectiveness as initial monotherapy for epileptic seizures and syndromes

PURPOSE

To assess which antiepileptic medications (AEDs) have the best evidence for long-term efficacy or effectiveness as initial monotherapy for patients with newly diagnosed or untreated epilepsy.

METHODS

A 10-member subcommission of the Commission on Therapeutic Strategies of The International League Against Epilepsy (ILAE), including adult and pediatric epileptologists, clinical pharmacologists, clinical trialists, and a statistician evaluated available evidence found through a structured literature review including MEDLINE, Current Contents and the Cochrane Library for all applicable articles from 1940 until July 2005. Articles dealing with different seizure types (for different age groups) and two epilepsy syndromes were assessed for quality of evidence (four classes) based on predefined criteria. Criteria for class I classification were a double-blind randomized controlled trial (RCT) design, >or=48-week treatment duration without forced exit criteria, information on >or=24-week seizure freedom data (efficacy) or >or=48-week retention data (effectiveness), demonstration of superiority or 80% power to detect a <or=20% relative difference in efficacy/effectiveness versus an adequate comparator, and appropriate statistical analysis. Class II studies met all class I criteria except for having either treatment duration of 24 to 47 weeks or, for noninferiority analysis, a power to only exclude a 21-30% relative difference. Class III studies included other randomized double-blind and open-label trials, and class IV included other forms of evidence (e.g., expert opinion, case reports). Quality of clinical trial evidence was used to determine the strength of the level of recommendation.

RESULTS

A total of 50 RCTs and seven meta-analyses contributed to the analysis. Only four RCTs had class I evidence, whereas two had class II evidence; the remainder were evaluated as class III evidence. Three seizure types had AEDs with level A or level B efficacy and effectiveness evidence as initial monotherapy: adults with partial-onset seizures (level A, carbamazepine and phenytoin; level B, valproic acid), children with partial-onset seizures (level A, oxcarbazepine; level B, None), and elderly adults with partial-onset seizures (level A, gabapentin and lamotrigine; level B, None). One adult seizure type [adults with generalized-onset tonic-clonic (GTC) seizures], two pediatric seizure types (GTC seizures and absence seizures), and two epilepsy syndromes (benign epilepsy with centrotemporal spikes and juvenile myoclonic epilepsy) had no AEDs with level A or level B efficacy and effectiveness evidence as initial monotherapy.

CONCLUSIONS

This evidence-based guideline focused on AED efficacy or effectiveness as initial monotherapy for patients with newly diagnosed or untreated epilepsy. The absence of rigorous comprehensive adverse effects data makes it impossible to develop an evidence-based guideline aimed at identifying the overall optimal recommended initial-monotherapy AED. There is an especially alarming lack of well-designed, properly conducted RCTs for patients with generalized seizures/epilepsies and for children in general. The majority of relevant existing RCTs have significant methodologic problems that limit their applicability to this guideline's clinically relevant main question. Multicenter, multinational efforts are needed to design, conduct and analyze future clinically relevant RCTs that can answer the many outstanding questions identified in this guideline. The ultimate choice of an AED for any individual patient with newly diagnosed or untreated epilepsy should include consideration of the strength of the efficacy and effectiveness evidence for each AED along with other variables such as the AED safety and tolerability profile, pharmacokinetic properties, formulations, and expense. When selecting a patient's AED, physicians and patients should consider all relevant variables and not just efficacy and effectiveness.

Effects of lamotrigine monotherapy in patients with newly diagnosed juvenile myoclonic epilepsy: An open-label study

BACKGROUND

It is important that drug therapy for juvenile myoclonic epilepsy(JME), a lifelong disorder requiring long-term therapy, is effective and well tolerated with long-term use. Lamotrigine as monotherapy or adjunctive therapy has been demonstrated to be effective in reducing the frequency of partial and generalized seizures in short- and long-term studies in children, adolescents, adults, and elderly patients with epilepsy, including those with JME. With its tolerability profile and spectrum of efficacy, lamotrigine might be an appropriate option for newly diagnosed patients with JME, a possibility that has not been empirically assessed.

OBJECTIVE

The aim of this study was to assess the efficacy and tolerability of lamotrigine monotherapy in patients with newly diagnosed JME.

METHODS

This open-label study was conducted at 18 clinical sites across the United States. Patients aged ≥12 years with newly diagnosed JME and who had experienced at least 1 generalized motor seizure since diagnosis but were antiepileptic treatment-naive or had received inappropriate treatment due to misdiagnosis were enrolled. During the first 8 weeks of the study, lamotrigine (25-mg or 100-mg tablets) was introduced (to a maximum dosage of 100-500 mg/d, based on instructions in the package insert and clinical response). This dose escalation was followed by a 24-week treatment phase during which lamotrigine dose could be adjusted as needed to achieve optimal clinical benefit. Efficacy end points included the rates of patients with a decrease from baseline of at least 50% in the frequency of myoclonic, tonic-clonic, and absence seizures; and the rate of patients with mild, moderate, or marked improvement from baseline in global clinical status as perceived by the investigators. Adverse events were recorded in patient diaries, and diary information was reviewed by study personnel at clinic visits. Results were analyzed using descriptive statistics.

RESULTS

Twenty-nine patients (17 females, 12 males; mean [SD] age, 24.0 [11.3] years [range, 12-50 years]) were included in the efficacy analysis. During the lamotrigine monotherapy treatment period, 58% of patients experienced a reduction from baseline of at least 50% in days with myoclonic seizures, and 56% and 38% of patients experienced a reduction of at least 50% in the frequency of generalized tonic-clonic seizures and absence seizures, respectively. At week 24 of the monotherapy phase, investigators perceived that 72% of patients had shown mild, moderate, or marked improvement in global clinical status relative to the start of the study.

CONCLUSIONS

In this study, lamotrigine monotherapy given to patients with newly diagnosed JME was associated with a reduction in the frequency of seizures and improvement in global clinical status as rated by the investigators. Lamotrigine was generally well tolerated.

Lamotrigine for patients with juvenile myoclonic epilepsy following prior treatment with valproate: results of an open-label study

This open-label study was designed to evaluate lamotrigine monotherapy as a possible alternative in patients with juvenile myoclonic epilepsy who previously failed treatment with valproate. Patients (n=63) were transitioned from valproate to lamotrigine during an 8-week escalation phase followed by 24 weeks of lamotrigine monotherapy. On Week 24 of the treatment phase, investigators judged that 50 and 67% of patients completing the study had shown mild, moderate, or marked improvement in adverse events and global clinical status, respectively, and 76% of patients rated lamotrigine as somewhat better (13%) or much better (63%) than valproate. The majority of patients completing the study experienced no deterioration of seizure control when switching from valproate to lamotrigine. These results support additional research on lamotrigine in juvenile myoclonic epilepsy.

Efficacy and safety of lamotrigine in pediatric patients

Accumulating data suggest that lamotrigine, which has been available for adult use in epilepsy for more than a decade in clinical practice, also confers effective, well-tolerated control of a range of childhood epilepsies. Lamotrigine is currently approved for the treatment of epilepsy by regulatory authorities in 93 countries, more than 70 of which have approved its use in pediatric patients on the basis of data from well-controlled clinical trials. The controlled clinical trials data have been supplemented over the years by clinical practice data, primarily from uncontrolled studies, confirming or demonstrating additional efficacy of lamotrigine for a range of seizure types. This article reviews the data from well-controlled clinical trials and studies conducted in clinical practice to present an updated perspective on the efficacy and safety of lamotrigine in pediatric patients.

Adolescent issues in epilepsy

Approximately one third of new cases of epilepsy have their onset before age 20 years. Many children will enter adolescence with epilepsy or have an onset of seizures during adolescence. Adolescence is a time of dramatic change in growth, hormonal, psychologic, and social situations. Seizure frequency, teenage pregnancy, driving, and alcohol and drug use often become major issues during the adolescent years. Furthermore, adolescents often have difficulty accepting the chronicity of epilepsy and complying with medications, which can result in physical injury and perceived or real obstacles to employment, thereby contributing to low morale. Both pediatricians and neurologists should be aware of adolescent issues in epilepsy.

Ultrastructure of Purkinje cell perikarya and their dendritic processes in the rat cerebellar cortex in experimental encephalopathy induced by chronic application of valproate

Long-term intragastric administration of the antiepileptic drug sodium valproate (Vuprol Polfa) to rats for 1, 3, 6, 9 and 12 months, once daily at the effective dose of 200 mg/kg body weight showed morphological evidence of encephalopathy, manifested by numerous nonspecific changes within Purkinje cell perikarya and their dendritic processes. The first ultrastructural abnormalities appeared after 3 months. They became more severe in animals with longer survival and were most pronounced after 12 months. The changes were maintained both 1 and 3 months after drug withdrawal. Mitochondria of Purkinje cell perikarya were most severely affected. Damage to mitochondria was accompanied by disintegration and fragmentation of granular endoplasmic reticulum, dilation of channels and cisterns of Golgi apparatus, enlargement of smooth endoplasmic reticulum elements including submembranous cisterns, and accumulation of profuse lipofuscin deposits. Frequently, Purkinje cells appeared as dark ischemic neurones, with focally damaged cellular membrane and features of disintegration. Swollen Bergmann's astrocytes were seen among damaged Purkinje cells or at the site of their loss. The general pattern of submicroscopic alterations of Purkinje cell perikarya suggested severe disorders in several intercellular biochemical extents, including inhibition of oxidative phosphorylation and abnormal protein synthesis, both of which could lead to lethal damage. Ultrastructural abnormalities within dendrites were characterized by damage to elements of smooth endoplasmic reticulum, which was considerably enlarged, with formation of large vacuolar structures situated deep in the dendroplasm. Mitochondrial lesions and alterations in cytoskeletal elements--disintegration of microtubules or even their complete loss--were also observed. The general pattern of abnormalities within the organelles and cytoskeletal elements of dendritic processes in Purkinje cells in the VPA chronic experimental model imply that there are disturbances in detoxication processes. Furthermore these changes were irreversible, as they were maintained after drug withdrawal.

'Why getting fat, Doc?' Weight gain and psychotropic medications

OBJECTIVES

Weight gain associated with the use of psychotropic medications is a common clinical problem that is of particular importance because of its effects on the general health of psychiatric patients and their compliance with treatment. This paper aims to explore this issue and discuss the mechanisms of weight gain and methods of prevention.

METHOD

A literature review (Index Medicus/Medline) was carried out as well as a review of other relevant papers and data known to the authors.

RESULTS

Significant weight gain may result in considerable morbidity. The majority of psychotropic medications are associated with weight gain, however, the mechanisms of weight gain are often complex and poorly understood.

CONCLUSION

Clinically, weight gain can be anticipated and often managed with some success in the majority of psychiatric patients with simple but relatively effective measures. It is important for clinicians to be aware of this common clinical problem and educate patients from the outset, monitoring them regularly and intervening when necessary.

The use of lamotrigine in juvenile myoclonic epilepsy

Lamotrigine (LTG) was used in 12 patients with juvenile myoclonic epilepsy (JME) who either had sodium valproate (VPA) side effects or did not wish to take VPA. Five patients are now fully controlled on LTG monotherapy. Side-effects were corrected by VPA withdrawal or reduction except for severe weight gain. In three patients it was not possible to withdraw VPA due to the re-emergence of myoclonus, suggesting LTG-VPA synergism. Two patients had successful pregnancies whilst taking LTG. Lamotrigine is a useful alternative in the management of JME.

Juvenile myoclonic epilepsy

Juvenile myoclonic epilepsy is a relatively common, though under diagnosed, form of epilepsy that commences in adolescence. The distinguishing symptoms, diagnosis and medical management are discussed.