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Vranic-Peters M, O'Brien P, Seneviratne U, Reynolds A, Lai A, Grayden DB, Cook MJ, Peterson ADH. Response to photic stimulation as a measure of cortical excitability in epilepsy patients. Front Neurosci 2024; 17:1308013. [PMID: 38249581 PMCID: PMC10796504 DOI: 10.3389/fnins.2023.1308013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 12/12/2023] [Indexed: 01/23/2024] Open
Abstract
Studying states and state transitions in the brain is challenging due to nonlinear, complex dynamics. In this research, we analyze the brain's response to non-invasive perturbations. Perturbation techniques offer a powerful method for studying complex dynamics, though their translation to human brain data is under-explored. This method involves applying small inputs, in this case via photic stimulation, to a system and measuring its response. Sensitivity to perturbations can forewarn a state transition. Therefore, biomarkers of the brain's perturbation response or "cortical excitability" could be used to indicate seizure transitions. However, perturbing the brain often involves invasive intracranial surgeries or expensive equipment such as transcranial magnetic stimulation (TMS) which is only accessible to a minority of patient groups, or animal model studies. Photic stimulation is a widely used diagnostic technique in epilepsy that can be used as a non-invasive perturbation paradigm to probe brain dynamics during routine electroencephalography (EEG) studies in humans. This involves changing the frequency of strobing light, sometimes triggering a photo-paroxysmal response (PPR), which is an electrographic event that can be studied as a state transition to a seizure state. We investigate alterations in the response to these perturbations in patients with genetic generalized epilepsy (GGE), with (n = 10) and without (n = 10) PPR, and patients with psychogenic non-epileptic seizures (PNES; n = 10), compared to resting controls (n = 10). Metrics of EEG time-series data were evaluated as biomarkers of the perturbation response including variance, autocorrelation, and phase-based synchrony measures. We observed considerable differences in all group biomarker distributions during stimulation compared to controls. In particular, variance and autocorrelation demonstrated greater changes in epochs close to PPR transitions compared to earlier stimulation epochs. Comparison of PPR and spontaneous seizure morphology found them indistinguishable, suggesting PPR is a valid proxy for seizure dynamics. Also, as expected, posterior channels demonstrated the greatest change in synchrony measures, possibly reflecting underlying PPR pathophysiologic mechanisms. We clearly demonstrate observable changes at a group level in cortical excitability in epilepsy patients as a response to perturbation in EEG data. Our work re-frames photic stimulation as a non-invasive perturbation paradigm capable of inducing measurable changes to brain dynamics.
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Affiliation(s)
- Michaela Vranic-Peters
- Department of Biomedical Engineering, The University of Melbourne, Melbourne, VIC, Australia
| | - Patrick O'Brien
- Department of Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, VIC, Australia
| | - Udaya Seneviratne
- Department of Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, VIC, Australia
| | - Ashley Reynolds
- Department of Biomedical Engineering, The University of Melbourne, Melbourne, VIC, Australia
| | - Alan Lai
- Department of Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, VIC, Australia
| | - David B. Grayden
- Department of Biomedical Engineering, The University of Melbourne, Melbourne, VIC, Australia
| | - Mark J. Cook
- Department of Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, VIC, Australia
| | - Andre D. H. Peterson
- Department of Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, VIC, Australia
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Gurrell R, Iredale P, Evrard A, Duveau V, Ruggiero C, Roucard C. Pronounced antiseizure activity of the subtype-selective GABA A positive allosteric modulator darigabat in a mouse model of drug-resistant focal epilepsy. CNS Neurosci Ther 2022; 28:1875-1882. [PMID: 35965432 PMCID: PMC9532903 DOI: 10.1111/cns.13927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/11/2022] [Accepted: 07/12/2022] [Indexed: 11/28/2022] Open
Abstract
Aim Darigabat is an α2/3/5 subunit‐selective positive allosteric modulator of GABAA receptors that has demonstrated broad‐spectrum activity in several preclinical models of epilepsy as well as in a clinical photoepilepsy trial. The objective here was to assess the acute antiseizure effect of darigabat in the mesial temporal lobe epilepsy (MTLE) mouse model of drug‐resistant focal seizures. Methods The MTLE model is generated by single unilateral intrahippocampal injection of low dose (1 nmole) kainic acid in adult mice, and subsequent epileptiform activity is recorded following implantation of a bipolar electrode under general anesthesia. After a period of epileptogenesis (~4 weeks), spontaneous and recurrent hippocampal paroxysmal discharges (HPD; focal seizures) are recorded using intracerebral electroencephalography. The number and cumulated duration of HPDs were recorded following administration of vehicle (PO), darigabat (0.3–10 mg kg−1, PO), and positive control diazepam (2 mg kg−1, IP). RESULTS Darigabat dose‐dependently reduced the expression of HPDs, demonstrating comparable efficacy profile to diazepam at doses of 3 and 10 mg kg−1. CONCLUSIONS Darigabat exhibited a robust efficacy profile in the MTLE model, a preclinical model of drug‐resistant focal epilepsy. A Phase II proof‐of‐concept placebo‐controlled, adjunctive‐therapy trial (NCT04244175) is ongoing to evaluate efficacy and safety of darigabat in patients with drug‐resistant focal seizures.
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Bialer M, Johannessen SI, Koepp MJ, Levy RH, Perucca E, Perucca P, Tomson T, White HS. Progress report on new antiepileptic drugs: A summary of the Sixteenth Eilat Conference on New Antiepileptic Drugs and Devices (EILAT XVI): II. Drugs in more advanced clinical development. Epilepsia 2022; 63:2883-2910. [PMID: 35950617 DOI: 10.1111/epi.17376] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 07/19/2022] [Accepted: 07/25/2022] [Indexed: 11/27/2022]
Abstract
The Sixteenth Eilat Conference on New Antiepileptic Drugs and Devices (EILAT XVI) was held in Madrid, Spain on May 22-25, 2022 and was attended by 157 delegates from 26 countries representing basic and clinical science, regulatory agencies, and pharmaceutical industries. One day of the conference was dedicated to sessions presenting and discussing investigational compounds under development for the treatment of seizures and epilepsy. The current progress report summarizes recent findings and current knowledge for seven of these compounds in more advanced clinical development for which either novel preclinical or patient data are available. These compounds include bumetanide and its derivatives, darigabat, ganaxolone, lorcaserin, soticlestat, STK-001, and XEN1101. Of these, ganaxolone was approved by the US Food and Drug Administration in March 2022 for the treatment of seizures associated with cyclin-dependent kinase-like 5 deficiency disorder in patients 2 years of age and older.
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Affiliation(s)
- Meir Bialer
- Institute for Drug Research, Faculty of Medicine, School of Pharmacy, and David R. Bloom Center for Pharmacy, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Svein I Johannessen
- National Center for Epilepsy, Sandvika, Norway.,Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Matthias J Koepp
- Department of Clinical and Experimental Epilepsy, University College London Queen Square Institute of Neurology, London, UK
| | - René H Levy
- Department of Pharmaceutics and Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Emilio Perucca
- Department of Medicine (Austin Health), University of Melbourne, Melbourne, Victoria, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Piero Perucca
- Department of Medicine (Austin Health), University of Melbourne, Melbourne, Victoria, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Bladin-Berkovic Comprehensive Epilepsy Program, Department of Neurology, Austin Health, Melbourne, Victoria, Australia.,Department of Neurology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Torbjörn Tomson
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - H Steve White
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington, USA
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Asnis-Alibozek A, Detyniecki K. The unmet need for rapid epileptic seizure termination (REST). Epilepsy Behav Rep 2020; 15:100409. [PMID: 33490947 PMCID: PMC7804985 DOI: 10.1016/j.ebr.2020.100409] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/28/2020] [Accepted: 11/08/2020] [Indexed: 11/15/2022] Open
Abstract
Approximately 40% of epilepsy patients will continue to experience breakthrough seizures despite stable antiepileptic drug regimens. Rescue treatments have demonstrated efficacy and safety for select seizure emergencies. Outpatient administered intranasal and rectally delivered medications are regulatory approved for acute repetitive seizures (ARS), and injectable benzodiazepines are indicated for parenteral treatment of established status epilepticus. Despite these advances, no studies have been shown to abort an ongoing seizure following patient or caregiver home administration of therapy at the first clinical sign of seizure onset. Such treatment would require rapid systemic absorption without intravenous access, and evidence of seizure cessation within minutes of administration that is superior to placebo (eg, seizure self-regulation). Rapid epileptic seizure termination (REST) treatment may apply to multiple seizure emergencies beyond ARS, including focal or generalized seizures preceded by an aura, flurries of absence or myoclonic seizures, or prolonged focal and generalized seizures at high risk of progression to status epilepticus. Novel investigational drug delivery systems have demonstrated feasibility of intraictal delivery and seizure cessation by two minutes. Ongoing randomized trials of REST treatment for diverse seizure emergencies hold the potential to decrease bouts of mental and physical incapacitation in patients with drug-resistant epilepsy.
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Affiliation(s)
- Aviva Asnis-Alibozek
- University of Lynchburg, School of PA Medicine, Doctor of Medical Science Program (DMSc Candidate), Lynchburg, VA 24501, United States
| | - Kamil Detyniecki
- University of Miami Miller School of Medicine, Department of Neurology, Miami, FL 33136, United States
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Rathore C, Prakash S, Makwana P. Prevalence of photoparoxysmal response in patients with epilepsy: Effect of the underlying syndrome and treatment status. Seizure 2020; 82:39-43. [PMID: 32979604 DOI: 10.1016/j.seizure.2020.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE To prospectively study the prevalence of photoparoxysmal response (PPR) and its determinants in epilepsy patients. METHODS Consecutive patients, older than 2 years, undergoing EEG from January 2016 to December 2019 were prospectively studied for the presence of PPR. Patients with emergent EEG and those with only sleep record were excluded. Intermittent photic stimulation was performed as per standard techniques with frequencies from 1-30 Hz. RESULTS Of the 1893 subjects included, 1492 (78%) patients had epilepsy while 401 (22%) had other diagnoses. In epilepsy group, 1028 (68.7%) had focal epilepsy, 343 (21.6%) had generalized epilepsy, while (9.7%) patients had unclassified epilepsy. Overall, 36 (2.2%) patients with epilepsy had PPR. The mean age of these patients was 19.5 ± 9.4 years and 75% were females. PPR was noted in 5 (0.5%) patients with focal epilepsy and 31 (9%) patients with generalized epilepsies [p < 0.0001; Odds ratio: 20.3 (95% CI, 7.8 - 52.7)]. PPR was noted in 1.5% of treated and 18% of untreated patients with genetic generalized epilepsy (n = 145) and 22% of untreated patients with juvenile myoclonic epilepsy (n = 86). Patients with untreated epilepsy had 17 times higher odds of having PPR [p < 0.0001; Odds ratio: 17.6 (95% CI, 4.1 - 75.6)]. CONCLUSION Underlying epilepsy syndrome and treatment status are the two most important determinants of PPR. Variability in these two factors is largely responsible for the variable reported prevalence of PPR.
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Affiliation(s)
- Chaturbhuj Rathore
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Center, Sumandeep Vidyapeeth, Vadodara, Gujarat, India.
| | - Sanjay Prakash
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Center, Sumandeep Vidyapeeth, Vadodara, Gujarat, India
| | - Prayag Makwana
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Center, Sumandeep Vidyapeeth, Vadodara, Gujarat, India
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Abstract
Placebos impact epilepsy in a number of ways. Through randomized clinical trials, explicit clinical use, and also through implicit clinical use, placebos play a role in epilepsy. This chapter will discuss the reasons placebo is used, the determinants of placebo response in epilepsy, observations about placebo specific to epilepsy, and ways in which clinical trial design is impacted by placebo.
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Witkin JM, Li G, Golani LK, Xiong W, Smith JL, Ping X, Rashid F, Jahan R, Cerne R, Cook JM, Jin X. The Positive Allosteric Modulator of α2/3-Containing GABA A Receptors, KRM-II-81, Is Active in Pharmaco-Resistant Models of Epilepsy and Reduces Hyperexcitability after Traumatic Brain Injury. J Pharmacol Exp Ther 2020; 372:83-94. [PMID: 31694876 PMCID: PMC6927408 DOI: 10.1124/jpet.119.260968] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 10/17/2019] [Indexed: 12/14/2022] Open
Abstract
The imidizodiazepine, 5-(8-ethynyl-6-(pyridin-2-yl)-4H-benzo[f]imidazo[1,5-a][1,4]diazepin-3-yl)oxazole (KRM-II-81), is selective for α2/3-containing GABAA receptors. KRM-II-81 dampens seizure activity in rodent models with enhanced efficacy and reduced motor-impairment compared with diazepam. In the present study, KRM-II-81 was studied in assays designed to detect antiepileptics with improved chances of impacting pharmaco-resistant epilepsies. The potential for reducing neural hyperactivity weeks after traumatic brain injury was also studied. KRM-II-81 suppressed convulsions in corneal-kindled mice. Mice with kainate-induced mesial temporal lobe seizures exhibited spontaneous recurrent hippocampal paroxysmal discharges that were significantly reduced by KRM-II-81 (15 mg/kg, orally). KRM-II-81 also decreased convulsions in rats undergoing amygdala kindling in the presence of lamotrigine (lamotrigine-insensitive model) (ED50 = 19 mg/kg, i.p.). KRM-II-81 reduced focal and generalized seizures in a kainate-induced chronic epilepsy model in rats (20 mg/kg, i.p., three times per day). In mice with damage to the left cerebral cortex by controlled-cortical impact, enduring neuronal hyperactivity was dampened by KRM-II-81 (10 mg/kg, i.p.) as observed through in vivo two-photon imaging of layer II/III pyramidal neurons in GCaMP6-expressing transgenic mice. No notable side effects emerged up to doses of 300 mg/kg KRM-II-81. Molecular modeling studies were conducted: docking in the binding site of the α1β3γ2L GABAA receptor showed that replacing the C8 chlorine atom of alprazolam with the acetylene of KRM-II-81 led to loss of the key interaction with α1His102, providing a structural rationale for its low affinity for α1-containing GABAA receptors compared with benzodiazepines such as alprazolam. Overall, these findings predict that KRM-II-81 has improved therapeutic potential for epilepsy and post-traumatic epilepsy. SIGNIFICANCE STATEMENT: We describe the effects of a relatively new orally bioavailable small molecule in rodent models of pharmaco-resistant epilepsy and traumatic brain injury. KRM-II-81 is more potent and generally more efficacious than standard-of-care antiepileptics. In silico docking experiments begin to describe the structural basis for the relative lack of motor impairment induced by KRM-II-81. KRM-II-81 has unique structural and anticonvulsant effects, predicting its potential as an improved antiepileptic drug and novel therapy for post-traumatic epilepsy.
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Affiliation(s)
- Jeffrey M Witkin
- Department of Neurologic Surgery, Indiana University School of Medicine, Indianapolis, Indiana (W.X., X.P., R.C., X.J.); Department of Chemistry and Biochemistry, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin (J.M.W., G.L., L.K.G., F.R., R.J., J.M.C.); Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, Indiana (W.X., X.P., X.J.); and Laboratory of Antiepileptic Drug Discovery, St. Vincent's Hospital, Indianapolis, Indiana (J.L.S.)
| | - Guanguan Li
- Department of Neurologic Surgery, Indiana University School of Medicine, Indianapolis, Indiana (W.X., X.P., R.C., X.J.); Department of Chemistry and Biochemistry, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin (J.M.W., G.L., L.K.G., F.R., R.J., J.M.C.); Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, Indiana (W.X., X.P., X.J.); and Laboratory of Antiepileptic Drug Discovery, St. Vincent's Hospital, Indianapolis, Indiana (J.L.S.)
| | - Lalit K Golani
- Department of Neurologic Surgery, Indiana University School of Medicine, Indianapolis, Indiana (W.X., X.P., R.C., X.J.); Department of Chemistry and Biochemistry, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin (J.M.W., G.L., L.K.G., F.R., R.J., J.M.C.); Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, Indiana (W.X., X.P., X.J.); and Laboratory of Antiepileptic Drug Discovery, St. Vincent's Hospital, Indianapolis, Indiana (J.L.S.)
| | - Wenhui Xiong
- Department of Neurologic Surgery, Indiana University School of Medicine, Indianapolis, Indiana (W.X., X.P., R.C., X.J.); Department of Chemistry and Biochemistry, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin (J.M.W., G.L., L.K.G., F.R., R.J., J.M.C.); Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, Indiana (W.X., X.P., X.J.); and Laboratory of Antiepileptic Drug Discovery, St. Vincent's Hospital, Indianapolis, Indiana (J.L.S.)
| | - Jodi L Smith
- Department of Neurologic Surgery, Indiana University School of Medicine, Indianapolis, Indiana (W.X., X.P., R.C., X.J.); Department of Chemistry and Biochemistry, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin (J.M.W., G.L., L.K.G., F.R., R.J., J.M.C.); Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, Indiana (W.X., X.P., X.J.); and Laboratory of Antiepileptic Drug Discovery, St. Vincent's Hospital, Indianapolis, Indiana (J.L.S.)
| | - Xingjie Ping
- Department of Neurologic Surgery, Indiana University School of Medicine, Indianapolis, Indiana (W.X., X.P., R.C., X.J.); Department of Chemistry and Biochemistry, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin (J.M.W., G.L., L.K.G., F.R., R.J., J.M.C.); Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, Indiana (W.X., X.P., X.J.); and Laboratory of Antiepileptic Drug Discovery, St. Vincent's Hospital, Indianapolis, Indiana (J.L.S.)
| | - Farjana Rashid
- Department of Neurologic Surgery, Indiana University School of Medicine, Indianapolis, Indiana (W.X., X.P., R.C., X.J.); Department of Chemistry and Biochemistry, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin (J.M.W., G.L., L.K.G., F.R., R.J., J.M.C.); Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, Indiana (W.X., X.P., X.J.); and Laboratory of Antiepileptic Drug Discovery, St. Vincent's Hospital, Indianapolis, Indiana (J.L.S.)
| | - Rajwana Jahan
- Department of Neurologic Surgery, Indiana University School of Medicine, Indianapolis, Indiana (W.X., X.P., R.C., X.J.); Department of Chemistry and Biochemistry, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin (J.M.W., G.L., L.K.G., F.R., R.J., J.M.C.); Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, Indiana (W.X., X.P., X.J.); and Laboratory of Antiepileptic Drug Discovery, St. Vincent's Hospital, Indianapolis, Indiana (J.L.S.)
| | - Rok Cerne
- Department of Neurologic Surgery, Indiana University School of Medicine, Indianapolis, Indiana (W.X., X.P., R.C., X.J.); Department of Chemistry and Biochemistry, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin (J.M.W., G.L., L.K.G., F.R., R.J., J.M.C.); Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, Indiana (W.X., X.P., X.J.); and Laboratory of Antiepileptic Drug Discovery, St. Vincent's Hospital, Indianapolis, Indiana (J.L.S.)
| | - James M Cook
- Department of Neurologic Surgery, Indiana University School of Medicine, Indianapolis, Indiana (W.X., X.P., R.C., X.J.); Department of Chemistry and Biochemistry, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin (J.M.W., G.L., L.K.G., F.R., R.J., J.M.C.); Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, Indiana (W.X., X.P., X.J.); and Laboratory of Antiepileptic Drug Discovery, St. Vincent's Hospital, Indianapolis, Indiana (J.L.S.)
| | - Xiaoming Jin
- Department of Neurologic Surgery, Indiana University School of Medicine, Indianapolis, Indiana (W.X., X.P., R.C., X.J.); Department of Chemistry and Biochemistry, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin (J.M.W., G.L., L.K.G., F.R., R.J., J.M.C.); Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, Indiana (W.X., X.P., X.J.); and Laboratory of Antiepileptic Drug Discovery, St. Vincent's Hospital, Indianapolis, Indiana (J.L.S.)
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Kasteleijn-Nolst Trenite DGA, DiVentura BD, Pollard JR, Krauss GL, Mizne S, French JA. Suppression of the photoparoxysmal response in photosensitive epilepsy with cenobamate (YKP3089). Neurology 2019; 93:e559-e567. [PMID: 31292226 PMCID: PMC6709996 DOI: 10.1212/wnl.0000000000007894] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 03/18/2019] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To evaluate the effect of cenobamate in patients with photoparoxysmal-EEG response (PPR) to intermittent photic stimulation (IPS) as proof of principle of efficacy in patients with epilepsy. METHODS In this multicenter, single-blind study, adults with photosensitive epilepsy, with/without concomitant antiepileptic drug therapy, underwent IPS under 3 eye conditions after a single dose of placebo (day -1, day 2) or cenobamate (day 1; 100, 250, or 400 mg). Complete suppression was a standardized photosensitivity range reduction to 0 over ≥1 time points for all eye conditions. Partial suppression was a ≥3-point reduction over ≥3 testing times vs the same time points on day -1 in ≥1 eye condition. Pharmacokinetics and safety were assessed. RESULTS Of 6 evaluable patients, 5 reentered to receive higher doses. Cenobamate 100 mg produced partial suppression in 1 of 3 patients; 250 mg produced complete suppression in 1 of 4 and partial suppression in 4 of 4 patients; and 400 mg produced complete suppression in 1 of 4 and partial suppression in 2 of 4 patients. PPR was consistently reduced on days 1 and 2 (>24 hours after cenobamate) vs day -1 (placebo) with the 250- and 400-mg doses. Area under the plasma concentration-time curve (before dose to last measurable concentration) values between 201 and 400 μg/h/mL resulted in partial suppression in 4 of 6 (66%) patients. Most common adverse events were dizziness and somnolence. CONCLUSIONS This proof-of-principle study demonstrated that cenobamate is a potentially effective product for epilepsy. CLINICALTRIALSGOV IDENTIFIER NCT00616148. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that, for patients with photosensitive epilepsy, cenobamate suppresses IPS-induced PPR.
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Affiliation(s)
- Dorothee G A Kasteleijn-Nolst Trenite
- From the University Medical Center Utrecht (D.G.A.K.- N.T.), the Netherlands; Sapienza University (D.G.A.K.- N.T.), Rome, Italy; Epilepsy Study Consortium (B.D.D., J.A.F.), Reston, VA; University of Pennsylvania (J.R.P.), Philadelphia; Johns Hopkins University (G.L.K.), Baltimore, MD; MedVal Scientific Information Services (S.M.), Princeton, NJ; and NYU Langone Comprehensive Epilepsy Center (J.A.F.), New York, NY.
| | - Bree D DiVentura
- From the University Medical Center Utrecht (D.G.A.K.- N.T.), the Netherlands; Sapienza University (D.G.A.K.- N.T.), Rome, Italy; Epilepsy Study Consortium (B.D.D., J.A.F.), Reston, VA; University of Pennsylvania (J.R.P.), Philadelphia; Johns Hopkins University (G.L.K.), Baltimore, MD; MedVal Scientific Information Services (S.M.), Princeton, NJ; and NYU Langone Comprehensive Epilepsy Center (J.A.F.), New York, NY
| | - John R Pollard
- From the University Medical Center Utrecht (D.G.A.K.- N.T.), the Netherlands; Sapienza University (D.G.A.K.- N.T.), Rome, Italy; Epilepsy Study Consortium (B.D.D., J.A.F.), Reston, VA; University of Pennsylvania (J.R.P.), Philadelphia; Johns Hopkins University (G.L.K.), Baltimore, MD; MedVal Scientific Information Services (S.M.), Princeton, NJ; and NYU Langone Comprehensive Epilepsy Center (J.A.F.), New York, NY
| | - Gregory L Krauss
- From the University Medical Center Utrecht (D.G.A.K.- N.T.), the Netherlands; Sapienza University (D.G.A.K.- N.T.), Rome, Italy; Epilepsy Study Consortium (B.D.D., J.A.F.), Reston, VA; University of Pennsylvania (J.R.P.), Philadelphia; Johns Hopkins University (G.L.K.), Baltimore, MD; MedVal Scientific Information Services (S.M.), Princeton, NJ; and NYU Langone Comprehensive Epilepsy Center (J.A.F.), New York, NY
| | - Sarah Mizne
- From the University Medical Center Utrecht (D.G.A.K.- N.T.), the Netherlands; Sapienza University (D.G.A.K.- N.T.), Rome, Italy; Epilepsy Study Consortium (B.D.D., J.A.F.), Reston, VA; University of Pennsylvania (J.R.P.), Philadelphia; Johns Hopkins University (G.L.K.), Baltimore, MD; MedVal Scientific Information Services (S.M.), Princeton, NJ; and NYU Langone Comprehensive Epilepsy Center (J.A.F.), New York, NY
| | - Jacqueline A French
- From the University Medical Center Utrecht (D.G.A.K.- N.T.), the Netherlands; Sapienza University (D.G.A.K.- N.T.), Rome, Italy; Epilepsy Study Consortium (B.D.D., J.A.F.), Reston, VA; University of Pennsylvania (J.R.P.), Philadelphia; Johns Hopkins University (G.L.K.), Baltimore, MD; MedVal Scientific Information Services (S.M.), Princeton, NJ; and NYU Langone Comprehensive Epilepsy Center (J.A.F.), New York, NY
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French JA, Wechsler R, Gelfand MA, Pollard JR, Vazquez B, Friedman D, Gong LH, Kamemoto E, Isojarvi J, Cassella JV. Inhaled alprazolam rapidly suppresses epileptic activity in photosensitive participants. Epilepsia 2019; 60:1602-1609. [PMID: 31268555 DOI: 10.1111/epi.16279] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/11/2019] [Accepted: 06/13/2019] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Treatment options for seizure clusters are limited; the need for easy-to-administer treatments remains. The Staccato system delivers drug deep into the lung via inhalation. In this phase 2a study, we investigated the ability of three different doses of Staccato alprazolam to suppress the electroencephalographic (EEG) photoparoxysmal response (PPR) compared with placebo in participants with photosensitive seizures. METHODS Adults (18-60 years) with a diagnosis and history of PPR on EEG with or without an epilepsy diagnosis were eligible to participate. Participants received Staccato alprazolam 0.5, 1.0, and 2.0 mg, and Staccato placebo (twice) in random order. Intermittent photic stimulation and clinical assessments were performed at one predose and seven postdose time points. The primary endpoint of the study was the change in standardized photosensitivity range (SPR) in participants receiving each dose of Staccato alprazolam. RESULTS Fifteen participants with a prior epilepsy diagnosis were screened; five were enrolled, randomized, and completed the study. All participants were white females with a mean (SD) age of 27.2 (6.8) years. All doses of Staccato alprazolam reduced the SPR at 2 minutes; the effect was sustained through 4 hours for the 0.5-mg dose and 6 hours for the 1.0- and 2.0-mg doses. The magnitude and duration of sedation and sleepiness were dose-related. Four participants (80%) experienced ≥1 adverse event (AE); none was severe or serious. Cough, diarrhea, dysgeusia, oral dysesthesia, sedation, and somnolence were experienced by two participants (40%) each. SIGNIFICANCE This proof-of-concept study demonstrated that Staccato alprazolam 0.5, 1.0, and 2.0 mg rapidly suppressed epileptiform activity in photosensitive participants with epilepsy. The AE profile of Staccato alprazolam was similar to what has been reported for alprazolam for other indications. The results support further development of Staccato alprazolam as a rescue medication for the acute treatment of seizures.
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Affiliation(s)
- Jacqueline A French
- Department of Neurology, New York University School of Medicine, New York, New York
| | | | - Michael A Gelfand
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John R Pollard
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Blanca Vazquez
- Department of Neurology, New York University School of Medicine, New York, New York
| | - Daniel Friedman
- Department of Neurology, New York University School of Medicine, New York, New York
| | - Lily H Gong
- Alexza Pharmaceuticals, Mountain View, California
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Gurrell R, Gorman D, Whitlock M, Ogden A, Reynolds DS, DiVentura B, Abou-Khalil B, Gelfand M, Pollard J, Hogan RE, Krauss G, Sperling M, Vazquez B, Wechsler RT, Friedman D, Butt RP, French J. Photosensitive epilepsy. Neurology 2019; 92:e1786-e1795. [DOI: 10.1212/wnl.0000000000007271] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 12/17/2018] [Indexed: 12/13/2022] Open
Abstract
ObjectiveThe objective of this phase 2a study was to assess the activity of PF-06372865, a positive allosteric modulator (PAM) of α2/3/5 subunit-containing GABAA receptors with minimal activity at α1-containing receptors, which are believed to mediate many of the adverse events associated with benzodiazepines, in the epilepsy photosensitivity model as a proof-of-principle of efficacy.MethodsSeven participants with a photoparoxysmal response to intermittent photic stimulation (IPS) at baseline were randomized in a double-blind, 4-period cross-over study examining single doses of 17.5 and 52.5 mg PF-06372865, 2 mg lorazepam (active control), and placebo. Standardized photosensitivity ranges (SPRs) to IPS were recorded at screening, predose, and 1, 2, 4, and 6 hours postdose. The primary endpoint was the average least squares mean change in the SPR in the participant's most sensitive eye condition, across all time points.ResultsBoth doses of PF-06372865 produced a marked and statistically significant mean reduction in SPR compared to placebo, which was similar in degree to lorazepam. There was complete suppression of SPR in 6/7 participants following PF-06372865 or lorazepam administration. PF-06372865 was safe and well-tolerated.ConclusionPF-06372865 demonstrated highly robust efficacy. This demonstrates anticonvulsant activity of a novel α2/3/5-subtype selective GABAA PAM in humans. Further study of the antiepileptic properties of PF-06372865 is warranted.Clinicaltrials.gov identifierNCT02564029.Classification of evidenceThis study provides Class II evidence that for people with a stable photoparoxysmal response to intermittent photic stimulation, PF-06372865 reduces the SPR.
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Abstract
Photosensitivity, which is the hallmark of photosensitive epilepsy (PSE), is described as an abnormal EEG response to visual stimuli known as a photoparoxysmal response (PPR). The PPR is a well-recognized phenomenon, occurring in 2-14% of patients with epilepsy but its pathophysiology is not clearly understood. PPR is electrographically described as 2-5Hz spike, spike-wave, or slow wave complexes with frontal and paracentral prevalence. Diagnosis of PPR is confirmed using intermittent photic stimulation (IPS) as well as video monitoring. The PPR can be elicited by certain types of visual stimuli including flicker, high contrast gratings, moving patterns, and rapidly modulating luminance patterns which may be encountered during e.g., watching television, playing video games, or attending discotheques. Photosensitivity may present in different idiopathic (genetic) epilepsy syndromes e.g. juvenile myoclonic epilepsy (JME) as well as non-IGE syndromes e.g. severe myoclonic epilepsy of infancy. Consequently, PPR is present in patients with diverse seizure types including absence, myoclonic, and generalized tonic-clonic (GTC) seizures. Across syndromes, abnormalities in structural connectivity, functional connectivity, cortical excitability, cortical morphology, and behavioral and neuropsychological function have been reported. Treatment of photosensitivity includes antiepileptic drug administration, and the use of non-pharmacological agents, e.g. tinted or polarizing glasses, as well as occupational measures, e.g. avoidance of certain stimuli.
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Affiliation(s)
- Shervonne Poleon
- University of Alabama at Birmingham, Department of Neurology and UAB Epilepsy Center, Birmingham, AL, USA.
| | - Jerzy P Szaflarski
- University of Alabama at Birmingham, Department of Neurology and UAB Epilepsy Center, Birmingham, AL, USA
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Porter RJ. The photosensitivity model is not a model for partial (focal) seizures. Epilepsy Res 2016; 133:110-112. [PMID: 27908525 DOI: 10.1016/j.eplepsyres.2016.11.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 09/17/2016] [Accepted: 11/20/2016] [Indexed: 11/17/2022]
Abstract
New, more effective and less toxic medications are desperately needed for patients with partial (focal) epilepsy. Many hurdles prevent the appropriate study of promising compounds. One of these hurdles is the difficult gap between Phase I and Phase II-the expensive proof of concept to suggest that human trials in partial seizure patients will be successful. A short-cut, the photoparoxysmal response (PPR) model has recently been used to increase confidence in moving a compound into Phase II and III (K-N Trenite et al., 2015). This shortcut has substantial limitations. This article outlines these limitations in an effort to create full disclosure to all involved with development of drugs for partial seizures.
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Affiliation(s)
- Roger J Porter
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA; Department of Pharmacology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
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Affiliation(s)
- Dorothee Kasteleijn-Nolst Trenite
- University Medical Center, UMCU Lundlaan 6, 3584EA Utrecht, The Netherlands; Faculty of Medicine & Psychology Sapienza University, c/o Sant' Andrea Hospital Via di Grottarossa, 1035-1039, 00189, Roma, Italy.
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Porter RJ. The photosensitivity model is not a model for partial (focal) seizures-REBUTTAL. Epilepsy Res 2016; 133:121-122. [PMID: 27913075 DOI: 10.1016/j.eplepsyres.2016.11.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 09/17/2016] [Accepted: 11/20/2016] [Indexed: 12/01/2022]
Affiliation(s)
- Roger J Porter
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA; Department of Pharmacology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
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Franco V, French JA, Perucca E. Challenges in the clinical development of new antiepileptic drugs. Pharmacol Res 2016; 103:95-104. [DOI: 10.1016/j.phrs.2015.11.007] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 11/13/2015] [Accepted: 11/18/2015] [Indexed: 12/26/2022]
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Galizia EC, Myers CT, Leu C, de Kovel CGF, Afrikanova T, Cordero-Maldonado ML, Martins TG, Jacmin M, Drury S, Krishna Chinthapalli V, Muhle H, Pendziwiat M, Sander T, Ruppert AK, Møller RS, Thiele H, Krause R, Schubert J, Lehesjoki AE, Nürnberg P, Lerche H, Palotie A, Coppola A, Striano S, Gaudio LD, Boustred C, Schneider AL, Lench N, Jocic-Jakubi B, Covanis A, Capovilla G, Veggiotti P, Piccioli M, Parisi P, Cantonetti L, Sadleir LG, Mullen SA, Berkovic SF, Stephani U, Helbig I, Crawford AD, Esguerra CV, Kasteleijn-Nolst Trenité DGA, Koeleman BPC, Mefford HC, Scheffer IE, Sisodiya SM. CHD2 variants are a risk factor for photosensitivity in epilepsy. Brain 2015; 138:1198-207. [PMID: 25783594 PMCID: PMC4407192 DOI: 10.1093/brain/awv052] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 01/07/2015] [Indexed: 12/24/2022] Open
Abstract
Photosensitivity in epilepsy is common and has high heritability, but its genetic basis remains uncertain. Galizia et al. reveal an overrepresentation of unique variants of CHD2 — which encodes the transcriptional regulator ‘chromodomain helicase DNA-binding protein 2’ — in photosensitive epilepsies, and show that chd2 knockdown in zebrafish causes photosensitivity. Photosensitivity is a heritable abnormal cortical response to flickering light, manifesting as particular electroencephalographic changes, with or without seizures. Photosensitivity is prominent in a very rare epileptic encephalopathy due to de novo CHD2 mutations, but is also seen in epileptic encephalopathies due to other gene mutations. We determined whether CHD2 variation underlies photosensitivity in common epilepsies, specific photosensitive epilepsies and individuals with photosensitivity without seizures. We studied 580 individuals with epilepsy and either photosensitive seizures or abnormal photoparoxysmal response on electroencephalography, or both, and 55 individuals with photoparoxysmal response but no seizures. We compared CHD2 sequence data to publicly available data from 34 427 individuals, not enriched for epilepsy. We investigated the role of unique variants seen only once in the entire data set. We sought CHD2 variants in 238 exomes from familial genetic generalized epilepsies, and in other public exome data sets. We identified 11 unique variants in the 580 individuals with photosensitive epilepsies and 128 unique variants in the 34 427 controls: unique CHD2 variation is over-represented in cases overall (P = 2·17 × 10−5). Among epilepsy syndromes, there was over-representation of unique CHD2 variants (3/36 cases) in the archetypal photosensitive epilepsy syndrome, eyelid myoclonia with absences (P = 3·50 × 10−4). CHD2 variation was not over-represented in photoparoxysmal response without seizures. Zebrafish larvae with chd2 knockdown were tested for photosensitivity. Chd2 knockdown markedly enhanced mild innate zebrafish larval photosensitivity. CHD2 mutation is the first identified cause of the archetypal generalized photosensitive epilepsy syndrome, eyelid myoclonia with absences. Unique CHD2 variants are also associated with photosensitivity in common epilepsies. CHD2 does not encode an ion channel, opening new avenues for research into human cortical excitability.
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Affiliation(s)
- Elizabeth C Galizia
- 1 NIHR Biomedical Research Centre Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK 2 Epilepsy Society, Bucks, UK
| | | | - Costin Leu
- 1 NIHR Biomedical Research Centre Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK 2 Epilepsy Society, Bucks, UK
| | - Carolien G F de Kovel
- 4 Department of Medical Genetics Research, University Medical Centre Utrecht, The Netherlands
| | - Tatiana Afrikanova
- 5 Luxembourg Centre for Systems Biomedicine, University of Luxembourg, Esch-sur-Alzette, Luxembourg
| | | | - Teresa G Martins
- 5 Luxembourg Centre for Systems Biomedicine, University of Luxembourg, Esch-sur-Alzette, Luxembourg
| | - Maxime Jacmin
- 5 Luxembourg Centre for Systems Biomedicine, University of Luxembourg, Esch-sur-Alzette, Luxembourg
| | - Suzanne Drury
- 6 North East Thames Regional Genetics Laboratories, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - V Krishna Chinthapalli
- 1 NIHR Biomedical Research Centre Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK 2 Epilepsy Society, Bucks, UK
| | - Hiltrud Muhle
- 7 Department of Neuropaediatrics, University Medical Centre Schleswig-Holstein and Christian-Albrechts-University of Kiel, Kiel, Germany
| | - Manuela Pendziwiat
- 7 Department of Neuropaediatrics, University Medical Centre Schleswig-Holstein and Christian-Albrechts-University of Kiel, Kiel, Germany
| | - Thomas Sander
- 8 Cologne Centre for Genomics, University of Cologne, Cologne, Germany
| | | | - Rikke S Møller
- 9 Danish Epilepsy Centre, Dianalund, Denmark 10 Institute for Regional Health Services, University of Southern Denmark, Odense, Denmark
| | - Holger Thiele
- 8 Cologne Centre for Genomics, University of Cologne, Cologne, Germany
| | - Roland Krause
- 5 Luxembourg Centre for Systems Biomedicine, University of Luxembourg, Esch-sur-Alzette, Luxembourg
| | - Julian Schubert
- 11 Deptartment of Neurology and Epileptology, Hertie Institut for Clinical Brain Research, Tübingen, Germany
| | - Anna-Elina Lehesjoki
- 12 Folkhälsan Institute of Genetics and Neuroscience Centre, University of Helsinki, Helsinki, Finland 13 Research Programs Unit, Molecular Neurology, University of Helsinki, Helsinki, Finland
| | - Peter Nürnberg
- 8 Cologne Centre for Genomics, University of Cologne, Cologne, Germany
| | - Holger Lerche
- 11 Deptartment of Neurology and Epileptology, Hertie Institut for Clinical Brain Research, Tübingen, Germany
| | | | - Aarno Palotie
- 14 Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridgeshire, UK 15 Institute for Molecular Medicine Finland, University of Helsinki, Helsinki, Finland 16 Program in Medical and Population Genetics and Genetic Analysis Platform, The Broad Institute of MIT and Harvard, Cambridge, USA
| | - Antonietta Coppola
- 1 NIHR Biomedical Research Centre Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK 2 Epilepsy Society, Bucks, UK 17 Epilepsy Centre, Neurology Department, Federico II University of Naples, Naples, Italy
| | - Salvatore Striano
- 17 Epilepsy Centre, Neurology Department, Federico II University of Naples, Naples, Italy
| | - Luigi Del Gaudio
- 17 Epilepsy Centre, Neurology Department, Federico II University of Naples, Naples, Italy
| | - Christopher Boustred
- 6 North East Thames Regional Genetics Laboratories, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Amy L Schneider
- 18 Department of Medicine, University of Melbourne, Austin Health, Melbourne, Australia
| | - Nicholas Lench
- 6 North East Thames Regional Genetics Laboratories, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Bosanka Jocic-Jakubi
- 19 Department of Child Neurology, Paediatric Clinic, Clinical Centre Nis, Serbia 20 Department of Paediatric Neurology, Paediatric Clinic, Al Sabah Hospital, Kuwait
| | - Athanasios Covanis
- 21 Neurology Department, The Children's Hospital Agia Sophia, Athens, Greece
| | | | - Pierangelo Veggiotti
- 23 Department of Child Neurology and Psychiatry C. Mondino National Neurological Institute, Via Mondino, 2, 27100, Pavia, Italy 24 Brain and Behaviour Department, University of Pavia, Pavia, Italy
| | - Marta Piccioli
- 25 Neurophysiopathology Unit, San Filippo Neri Hospital, Rome, Italy
| | - Pasquale Parisi
- 26 Child Neurology, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy
| | - Laura Cantonetti
- 27 Neurorehabilitation Unit, Department of Neuroscience and Neurorehabilitation, IRCCS, Bambino Gesu' Children's Hospital, Rome, Italy
| | - Lynette G Sadleir
- 28 Department of Paediatrics and Child Health, School of Medicine and Health Sciences, University of Otago, Wellington, New Zealand
| | - Saul A Mullen
- 29 Florey Institute of Neurosciences and Mental Health, and Department of Paediatrics, University of Melbourne, Royal Children's Hospital, Melbourne, Australia
| | - Samuel F Berkovic
- 18 Department of Medicine, University of Melbourne, Austin Health, Melbourne, Australia
| | - Ulrich Stephani
- 7 Department of Neuropaediatrics, University Medical Centre Schleswig-Holstein and Christian-Albrechts-University of Kiel, Kiel, Germany
| | - Ingo Helbig
- 7 Department of Neuropaediatrics, University Medical Centre Schleswig-Holstein and Christian-Albrechts-University of Kiel, Kiel, Germany
| | - Alexander D Crawford
- 5 Luxembourg Centre for Systems Biomedicine, University of Luxembourg, Esch-sur-Alzette, Luxembourg
| | - Camila V Esguerra
- 30 Chemical Neuroscience Group, Biotechnology Centre of Oslo, University of Oslo, Oslo, Norway 31 Laboratory for Molecular Biodiscovery, University of Leuven, Leuven, Belgium
| | | | - Bobby P C Koeleman
- 4 Department of Medical Genetics Research, University Medical Centre Utrecht, The Netherlands
| | | | - Ingrid E Scheffer
- 18 Department of Medicine, University of Melbourne, Austin Health, Melbourne, Australia 29 Florey Institute of Neurosciences and Mental Health, and Department of Paediatrics, University of Melbourne, Royal Children's Hospital, Melbourne, Australia
| | - Sanjay M Sisodiya
- 1 NIHR Biomedical Research Centre Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK 2 Epilepsy Society, Bucks, UK
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Zaccara G, Giovannelli F, Schmidt D. Placebo and nocebo responses in drug trials of epilepsy. Epilepsy Behav 2015; 43:128-34. [PMID: 25703333 DOI: 10.1016/j.yebeh.2014.12.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 12/02/2014] [Accepted: 12/04/2014] [Indexed: 12/19/2022]
Abstract
Placebo response can be defined as any therapeutic change on placebo, while the nocebo response is any ill effect during placebo exposure. Several meta-analytic approaches have investigated the extent of placebo response in randomized, placebo-controlled, clinical trials of focal epilepsies. Placebo response rates (proportion of patients with ≥50% improvement of seizures versus baseline) ranging from 9.9% up to 15.2% have been reported. Interestingly, a sham response of 15.8% has been noted in trials of transcranial magnetic stimulation. Recently, nocebo response rates of 60.3% and 3.9% were noted, which were defined as the proportion of patients with adverse events (AEs) and those withdrawing because of intolerable AEs, respectively. Factors which were found to influence placebo response were as follows: the year of publication (with more recent studies showing higher rates of placebo response), some clinical characteristics of recruited patients (lower placebo response rates with a history of 7 or more prior lifetime AEDs, a high baseline seizure frequency, prior epilepsy surgery, and higher age at diagnosis), trial design and statistical analysis, and whether studies have been conducted in children or adults. Furthermore, placebo and nocebo rates were correlated with respective seizure outcome and adverse events of the experimental AED. Several mechanisms of placebo and nocebo responses are discussed. Specifically, the role of positive or negative expectations of patients and of investigators may influence the placebo and the nocebo response. Finally, recommendations are given on how to address placebo and nocebo responses in clinical practice.
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Affiliation(s)
- Gaetano Zaccara
- Unit of Neurology, Department of Medicine, Florence Health Authority, Firenze, Italy.
| | - Fabio Giovannelli
- Unit of Neurology, Department of Medicine, Florence Health Authority, Firenze, Italy; Department of Neuroscience, Psychology, Pharmacology and Child Health (NEUROFARBA), University of Florence, Firenze, Italy
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Kasteleijn-Nolst Trenité DG, Hirsch E, Reed RC, W. Abou-Khalil B, Schmidt B. Comment from Dorothée G.A. Kasteleijn-Nolst Trenité, Edouard Hirsch, Ronald C. Reed, Bassel Abou-Khalil, and Bernd Schmidt on: How predictive are photosensitive epilepsy models as proof of principle trials for epilepsy? Seizure 2014; 23:922-3. [DOI: 10.1016/j.seizure.2014.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 08/09/2014] [Indexed: 11/16/2022] Open
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Yuen ES, Sims JR. How predictive are photosensitive epilepsy models as proof of principle trials for epilepsy? Seizure 2014; 23:490-3. [DOI: 10.1016/j.seizure.2014.03.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 03/04/2014] [Accepted: 03/19/2014] [Indexed: 11/26/2022] Open
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