RESUMEN
OBJECTIVE: To assess effectiveness and tolerability of first-line and conversion to lacosamide monotherapy for focal seizures. MATERIALS AND METHODS: Retrospective, non-interventional chart review of lacosamide monotherapy patients aged ≥16 years in Europe. Outcomes included retention rate at observational point (OP) 3 (12 ± 3 months), seizure freedom rates at OP2 (6 ± 3 months) and OP3 and adverse drug reactions (ADRs). RESULTS: A total of 439 patients were included (98 first-line and 341 conversion to monotherapy; 128 aged ≥65 years [25 first-line and 103 conversion to monotherapy]). First-line and conversion to monotherapy retention rates were 60.2% (59/98; 95% confidence interval [CI] 49.8%-70.0%) and 62.5% (213/341; 57.1%-67.6%), respectively. Kaplan-Meier estimates of 12-month retention rates were 81.2% and 91.4% for first-line and conversion to monotherapy, respectively. First-line and conversion to monotherapy retention rates in patients aged ≥65 years were 60.0% (38.7%-78.9%) and 68.9% (59.1%-77.7%), respectively. At OP2, 66.3% of first-line and 63.0% of conversion to monotherapy patients were seizure free. At OP3, 60.2% of first-line and 52.5% of conversion to monotherapy patients were seizure free. In the ≥65 years subgroup, seizure freedom rates at OP2 were 72.0% and 68.0% for first-line and converted to monotherapy, respectively, and at OP3, 68.0% and 56.3%, respectively. Overall, 52 of 439 (11.8%) patients reported ADRs (16.4% in ≥65 years subgroup), most commonly dizziness (5.0%), headache (2.1%) and somnolence (1.6%). CONCLUSIONS: Lacosamide was effective and well tolerated as first-line or conversion to monotherapy in a clinical setting in adult and elderly patients with focal seizures.
Asunto(s)
Acetamidas/uso terapéutico , Anticonvulsivantes/uso terapéutico , Convulsiones/tratamiento farmacológico , Adolescente , Adulto , Anciano , Europa (Continente) , Femenino , Humanos , Lacosamida , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
OBJECTIVES: Mesial temporal lobe epilepsy syndrome (MTLE) with specific electrophysiological and clinical characteristics and hippocampal sclerosis (HS) on MRI is considered the prototype of a syndrome with good surgical prognosis. Ictal onset zones in MTLE have been found to extend outside the hippocampus and neocortical seizures often involve mesial structures. It can, thus, be questioned whether MTLE with HS is different from lesional temporal epilepsies with respect to electro-clinical characteristics and surgical prognosis. We assessed whether MTLE with HS is distinguishable from lesional TLE and which criteria determine surgical outcome. METHODS: People in a retrospective cohort of 389 individuals with MRI abnormalities who underwent temporal lobectomy, were divided into "HS only" or "lesional" TLEs. Twenty-six presented with dual pathology and were excluded from further analysis. We compared surgical outcome and electro-clinical characteristics. RESULTS: Over half (61%) had "HS only." Four electro-clinical characteristics (age at epilepsy onset, febrile seizures, memory dysfunction and contralateral dystonic posturing) distinguished "HS only" from "lesional" TLE, but there was considerable overlap. Seizure freedom 2 years after surgery (Engel class 1) was similar: 67% ("HS only") vs 69% ("lesional" TLE). Neither presence of HS nor electro-clinical criteria was associated with surgical outcome. CONCLUSIONS: Despite small differences in electrophysiological and clinical characteristics between MTLE with HS and lesional TLE, surgical outcomes are similar, indicating that aetiology seems irrelevant in the referral for temporal surgery.
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Lobectomía Temporal Anterior/efectos adversos , Epilepsia del Lóbulo Temporal/cirugía , Complicaciones Posoperatorias/epidemiología , Adulto , Epilepsia del Lóbulo Temporal/diagnóstico , Epilepsia del Lóbulo Temporal/diagnóstico por imagen , Femenino , Hipocampo/diagnóstico por imagen , Hipocampo/cirugía , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiologíaRESUMEN
The use of carbamazepine (CBZ) and oxcarbazepine (OXC) as first-line antiepileptic drugs in the treatment of focal epilepsy is limited by hyponatremia, a known adverse effect. Hyponatremia occurs in up to half of people taking CBZ or OXC and, although often assumed to be asymptomatic, it can lead to symptoms ranging from unsteadiness and mild confusion to seizures and coma. Hyponatremia is probably due to the antidiuretic properties of CBZ and OXC that are, at least partly, explained by stimulation of the vasopressin 2 receptor/aquaporin 2 pathway. No known genetic risk variants for CBZ- and OXC-induced hyponatremia exist, but likely candidate genes are part of the vasopressin water reabsorption pathway.
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Anticonvulsivantes/efectos adversos , Carbamazepina/análogos & derivados , Carbamazepina/efectos adversos , Hiponatremia/inducido químicamente , Animales , Humanos , Hiponatremia/epidemiología , Hiponatremia/genética , Hiponatremia/fisiopatología , Oxcarbazepina , FarmacogenéticaRESUMEN
Autosomal dominant lateral temporal lobe epilepsy (ADLTE) is characterized by focal seizures with auditory features or aphasia. Mutations in the leucine-rich glioma-inactivated 1 (LGI1) gene have been reported in up to 50% of families with ADLTE. Attention-deficit/hyperactivity disorder (ADHD) symptoms have not yet been reported in these families. Clinical data were collected from a family with five affected members. Leucine-rich glioma-inactivated 1 exons and boundaries were sequenced by standard methods. Attention-deficit/hyperactivity disorder symptoms were scored based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria. Affected members had seizures with auditory features and psychic auras, and some experienced nightmares. A heterozygous c.431+1G>A substitution in LGI1 was detected in all members. Significantly more hyperactivity symptoms were found in family members carrying the LGI1 mutation. This study expands the phenotypic spectrum associated with ADLTE due to LGI1 mutation and underlines the need for more systematic evaluation of ADHD and related symptoms.
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Trastorno por Déficit de Atención con Hiperactividad/etiología , Epilepsia del Lóbulo Temporal/complicaciones , Epilepsia del Lóbulo Temporal/genética , Salud de la Familia , Mutación/genética , Proteínas/genética , Trastorno por Déficit de Atención con Hiperactividad/genética , Niño , Análisis Mutacional de ADN , Femenino , Genes Dominantes , Humanos , Péptidos y Proteínas de Señalización Intracelular , Masculino , Fenotipo , Índice de Severidad de la Enfermedad , Adulto JovenRESUMEN
In recent years, several new antiepileptic drugs (AEDs) have been licensed: felbamate, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, tiagabine, topiramate, vigabatrin and zonisamide. These drugs have proven efficacy as add-on therapy in patients with difficult-to-treat partial epilepsy, as 20-50% of patients treated in add-on trials experienced a seizure reduction of >or=50%. Relatively few trials have been conducted to evaluate these drugs as monotherapy for patients with newly diagnosed epilepsy. In the monotherapy trials that have been conducted, the newer drugs were often as efficacious as conventional drugs, and their tolerability was often better. However, the methodology of these trials can be criticised. Because of the relative lack of robust data for the newer agents, the conventional drugs have thus far maintained their status as first-line monotherapy. However, when first-line monotherapy fails, an alternative drug has to be chosen from the available conventional and newer drugs. This article aims to give detailed background information on the newer AEDs in order to enable physicians to make a rational choice from the available drugs for individual patients. Data are provided for the different newer AEDs on mechanisms of action; efficacy in refractory partial epilepsy, newly diagnosed epilepsy in adults and generalised seizure types; adverse effects; pharmacokinetics; and use in special patient categories.
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Anticonvulsivantes/uso terapéutico , Evaluación de Medicamentos , Epilepsia/tratamiento farmacológico , Animales , Anticonvulsivantes/efectos adversos , Anticonvulsivantes/farmacocinética , Ensayos Clínicos como Asunto , Drogas en Investigación , Humanos , Selección de Paciente , Resultado del TratamientoRESUMEN
A 76-year-old man suffering from myelofibrosis with thrombocytopenia sustained an acute subdural haematoma with severe neurological deficit. He was treated initially by bedrest and dexamethasone. Craniotomy was contraindicated because his bleeding time exceeded 20 min in spite of multiple infusions of platelet concentrate. After 3 weeks his condition deteriorated with increase of the fluid collection shown by CT. Partial drainage of the haematoma by subdural puncture with a 22-gauge spinal needle resulted in complete recovery from the neurological deficit and complete resorption of the effusion. The case shows that it is possible to avoid craniotomy in the acute phase of a subdural haematoma in patients with bleeding disorders and that it may be advantageous to use needle evacuation instead of burr-hole drainage in the chronic phase.
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Hematoma Subdural/terapia , Punciones , Trombocitopenia/complicaciones , Anciano , Hematoma Subdural/complicaciones , Hematoma Subdural/diagnóstico por imagen , Humanos , Masculino , Succión , Tomografía Computarizada por Rayos XRESUMEN
The antiepileptic drug primidone is to be withdrawn from sale by January 2004. After this date, the drug will still be available for a time, but only on a limited basis. Most primidone users are elderly patients who have been prescribed this drug for many years. Changing to a new drug constitutes a health risk for them. If primidone treatment is discontinued too quickly, withdrawal seizures may appear, some of which may be severe. In patients who have not suffered an epileptic seizure for many years, discontinuing medication may be considered. Whenever continuation of anticonvulsive treatment is desirable, it may probably be a good idea to switch over to some newer antiepileptic drug. If a simple and quick substitution is essential, primidone may be replaced by its main metabolite: phenobarbital. General practitioners and neurologists are strongly advised to alter patients' medication in good time.
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Anticonvulsivantes/uso terapéutico , Epilepsia/tratamiento farmacológico , Primidona/uso terapéutico , Control de Medicamentos y Narcóticos/tendencias , Humanos , Fenobarbital/uso terapéutico , Síndrome de Abstinencia a Sustancias/etiología , Síndrome de Abstinencia a Sustancias/prevención & controlRESUMEN
Progressive myoclonus epilepsy type 1 of Unverricht-Lundborg (EPM1) is a rare disorder, associated with mutations in the cystatin B (CSTB) gene. The most prevalent molecular abnormality is an expansion of a dodecamer repeat in the promoter region of the CSTB gene, but point mutations in the CSTB gene have also been found. DNA examination may be useful in discriminating EPM1 from juvenile myoclonic epilepsy, and from other types of progressive myoclonus epilepsy. An early diagnosis is important to optimise treatment and to provide an adequate prognosis and prediction of recurrence.
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Cistatinas/genética , Inhibidores de Cisteína Proteinasa/genética , Epilepsias Mioclónicas Progresivas/genética , Cistatina B , Humanos , Epilepsias Mioclónicas Progresivas/diagnóstico , Epilepsias Mioclónicas Progresivas/terapia , Mutación Puntual , Pronóstico , Prevención SecundariaRESUMEN
Generic substitution is encouraged as a cost containment strategy for the management of health care resources. However, in epilepsy, the consequences of loss of symptom control are important, and antiepileptic drugs have narrow therapeutic indices. For this reason, generic substitution may be problematic, and certain health authorities have excluded antiepileptic drugs from overall policy recommendations on generic prescribing. The absence of bioequivalence data among generic forms and the relatively broad criteria for bioequivalence with the branded drug allow differences in drug exposure to arise that may be clinically relevant and necessitate monitoring of plasma levels when switching formulations to avoid loss of seizure control or emergence of side effects. Management of these issues carries a significant cost, which should be weighed carefully against the cost savings acquired when purchasing the drug. Both physicians and patients have a right to be informed and approve before pharmacists make a generic substitution or switch between generics.
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Anticonvulsivantes/uso terapéutico , Medicamentos Genéricos/uso terapéutico , Epilepsia/tratamiento farmacológico , Política de Salud , Anticonvulsivantes/farmacocinética , Prescripciones de Medicamentos , Medicamentos Genéricos/normas , Humanos , Educación del Paciente como Asunto , Equivalencia Terapéutica , Estados UnidosRESUMEN
The authors describe 12 pregnancies in women with epilepsy using lamotrigine (LTG) monotherapy. A seizure increase in nine pregnancies was probably related to a gradual decline of LTG level-to-dose ratio to 40% of baseline. After delivery, LTG kinetics returned swiftly to baseline, causing toxic side effects in some women. Frequent LTG level monitoring and appropriate dose adjustments are advised in the period before and during pregnancy and after delivery, especially in women on LTG monotherapy.
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Anticonvulsivantes/farmacocinética , Epilepsia/metabolismo , Complicaciones del Embarazo/metabolismo , Triazinas/farmacocinética , Adulto , Anticonvulsivantes/efectos adversos , Anticonvulsivantes/sangre , Estudios de Cohortes , Relación Dosis-Respuesta a Droga , Epilepsia/sangre , Epilepsia/tratamiento farmacológico , Femenino , Sangre Fetal/química , Humanos , Lamotrigina , Leche Humana/química , Embarazo , Complicaciones del Embarazo/sangre , Complicaciones del Embarazo/tratamiento farmacológico , Resultado del Embarazo , Estudios Prospectivos , Recurrencia , Estudios Retrospectivos , Triazinas/efectos adversos , Triazinas/sangreRESUMEN
The techniques introduced by Kimura and Ingram et al. were applied to assess the distribution of motor refractory periods (DMRPs) in peroneal nerve fibres of 28 diabetics with symptoms indicating polyneuropathy and in 28 controls. Results were compared with conventional motor nerve conduction velocity (MNCV) and compound muscle action potential (CMAP) measurements. MRP95 and MRP90 (the 5% and 10% slowest recovering fibres) obtained with Ingram's technique were prolonged in the diabetic patients. In the 26 patients with a value of MRP95 and MNCV, a prolonged MRP95 and a decreased MNCV were found in 12 patients. Thus conventional MNCV had a sensitivity of 46% to detect neuropathy; addition of MRP95 obtained with Ingram's technique raised the sensitivity to 73%. Specificity was 100% in both cases. With Kimura's technique or with the fast recovering fibres in Ingram's technique, it was not possible to discriminate the patients from the controls. This study indicates that measurement of the DMRP with the technique introduced by Ingram et al. improves the electrophysiological diagnosis of diabetic polyneuropathy.
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Neuropatías Diabéticas/fisiopatología , Electrofisiología/métodos , Neuronas Motoras/fisiología , Periodo Refractario Electrofisiológico/fisiología , Potenciales de Acción/fisiología , Adulto , Anciano , Análisis de Varianza , Femenino , Humanos , Masculino , Persona de Mediana Edad , Músculos/fisiopatologíaRESUMEN
PURPOSE: Stress is often noted by patients to be a precipitating factor in causing seizures. No precise data are, however, available. In 1995 for 250,000 inhabitants in The Netherlands, a serious life event occurred within a period of seven days. An extreme high water level in the province of Gelderland, with the possibility of a flood, made the government decide to evacuate people and their livestock. This retrospective study investigated the influence of this forced evacuation on the seizure frequency of patients with epilepsy, compared with patients of the same age and type of epilepsy living outside the evacuation area at the time of the threatening flood. METHODS: Information regarding epilepsy syndrome, seizure type, and frequency was derived from seizure diaries and medical histories of 30 evacuated patients and 30 matched control patients. RESULTS: Of the 30 evacuees, eight showed an increase and one a decrease in seizure frequency during or shortly after the evacuation period, compared with one and zero control patients, respectively. These results proved to be statistically significant (p < 0.05). CONCLUSIONS: Our data support the hypothesis that there is a relation, albeit small, between a stressful life event and seizure frequency.
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Desastres , Epilepsia/etiología , Acontecimientos que Cambian la Vida , Estrés Fisiológico/complicaciones , Comorbilidad , Planificación en Desastres/historia , Desastres/historia , Epilepsia/epidemiología , Femenino , Historia del Siglo XX , Humanos , Masculino , Persona de Mediana Edad , Países Bajos/epidemiología , Estudios Retrospectivos , Estrés Fisiológico/epidemiologíaRESUMEN
AIMS: To investigate the pharmacokinetic and pharmacodynamic profile of midazolam administered as a concentrated intranasal spray, compared with intravenous midazolam, in healthy adult subjects. METHODS: Subjects were administered single doses of 5 mg midazolam intranasally and intravenously in a cross-over design with washout period of 1 week. The total plasma concentrations of midazolam and the metabolite 1-hydroxymidazolam after both intranasal and intravenous administration were described with a single pharmacokinetic model. beta-band EEG activity was recorded and related to midazolam plasma concentrations using an exponential pharmacokinetic/pharmacodynamic model. RESULTS: Administration of the intranasal spray led to some degree of temporary irritation in all six subjects, who nevertheless found intranasal administration acceptable and not painful. The mean (+/-s.d.) peak plasma concentration of midazolam of 71 (+/-25 ng ml-1) was reached after 14 (+/-5 min). Mean bioavailability following intranasal administration was 0.83+/-0.19. After intravenous and intranasal administration, the pharmacokinetic estimates of midazolam were: mean volume of distribution at steady state 1.11+/-0.25 l kg-1, mean systemic clearance 16.1+/-4.1 ml min-1 kg-1 and harmonic mean initial and terminal half lives 8.4+/-2.4 and 79+/-30 min, respectively. Formation of the 1-hydroxymetabolite after intranasal administration did not exceed that after intravenous administration. CONCLUSIONS: In this study in healthy volunteers a concentrated midazolam nasal spray was easily administered and well tolerated. No serious complications of the mode of administration or the drug itself were reported. Rapid uptake and high bioavailability were demonstrated. The potential of midazolam given via a nasal spray in the acute treatment of status epilepticus and other seizure disruptions should be evaluated.
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Ansiolíticos/administración & dosificación , Ansiolíticos/farmacocinética , Midazolam/análogos & derivados , Midazolam/administración & dosificación , Midazolam/farmacocinética , Administración Intranasal , Adulto , Ansiolíticos/sangre , Disponibilidad Biológica , Estudios Cruzados , Femenino , Semivida , Humanos , Inyecciones Intravenosas , Masculino , Midazolam/sangre , Persona de Mediana Edad , Modelos Biológicos , Mucosa Nasal/metabolismoRESUMEN
PURPOSE: This study compares the cognitive effects of topiramate (TPM) with those of valproate (VPA) using efficacious doses of each drug when used as adjunctive therapy to carbamazepine (CBZ). A key question of the study is to what extent a more gradual introduction of TPM improves tolerability and prevents cognitive impairment. METHODS: The study is a multicenter, randomized, observer-blinded, parallel-group clinical trial with VPA or TPM given as first-line add-on therapy to steady-state treatment with CBZ. TPM is introduced at 25 mg and increased with weekly 25mg/d increments to a minimum dosage of 200 mg/d. The target dosage ranges from 200 to 400 mg/d for TPM and is 1800 mg/d for VPA. The study evaluates cognitive function changes from baseline to end point (after 20 weeks of treatment) and during titration (after 8 weeks of treatment). The primary outcome measure is the difference between the treatments (TPM versus VPA) in change from baseline to end point and change from baseline to titration, using a 95% confidence interval approach. RESULTS: For the 10 baseline-to-end point comparisons, one test measuring short-term verbal memory (Rey Auditory Verbal Learning Test) yields a statistically significant difference between the treatments (p = 0.02), showing worsening for TPM and improvement of scores for VPA. The 10 baseline-to-titration comparisons also show one statistically significant difference, again for a test measuring short-term memory (Recognition of Words; p = 0.04), showing a larger change in the negative direction for TPM. None of the mood tests or the test for subjective complaints shows statistically significant differences between the treatments, although more scores are in the negative direction for TPM during titration. CONCLUSION: Although the pattern of changes in the negative direction seems consistent with clinical information, the differences found between the treatments are small. An important finding of our study is that, when the results are compared with those of other studies, it is clear that gradual introduction of TPM can reduce the extent of cognitive impairment (with a maximum of about 0.6 SD).
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Anticonvulsivantes/uso terapéutico , Carbamazepina/uso terapéutico , Cognición/efectos de los fármacos , Epilepsias Parciales/tratamiento farmacológico , Fructosa/análogos & derivados , Ácido Valproico/uso terapéutico , Adolescente , Adulto , Anticonvulsivantes/efectos adversos , Anticonvulsivantes/farmacología , Carbamazepina/efectos adversos , Trastornos del Conocimiento/inducido químicamente , Trastornos del Conocimiento/diagnóstico , Quimioterapia Combinada , Epilepsias Parciales/psicología , Femenino , Fructosa/efectos adversos , Fructosa/farmacología , Fructosa/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Placebos , Desempeño Psicomotor , Topiramato , Resultado del Tratamiento , Ácido Valproico/efectos adversos , Ácido Valproico/farmacologíaRESUMEN
Genetic factors play a major role in the aetiology of idiopathic generalised epilepsies (IGEs). The present genome scan was designed to identify susceptibility loci that predispose to a spectrum of common IGE syndromes. Our collaborative study included 130 IGE-multiplex families ascertained through a proband with either an idiopathic absence epilepsy or juvenile myoclonic epilepsy, and one or more siblings affected by an IGE trait. In total, 413 microsatellite polymorphisms were genotyped in 617 family members. Non-parametric multipoint linkage analysis, using the GeneHunter program, provided significant evidence for a novel IGE susceptibility locus on chromosome 3q26 (Z(NPL) = 4.19 at D3S3725; P = 0.000017) and suggestive evidence for two IGE loci on chromosome 14q23 (Z(NPL) = 3.28 at D14S63; P = 0.000566), and chromosome 2q36 (Z(NPL) = 2.98 at D2S1371; P = 0.000535). The present linkage findings provide suggestive evidence that at least three genetic factors confer susceptibility to generalised seizures in a broad spectrum of IGE syndromes. The chromosomal segments identified harbour several genes involved in the regulation of neuronal ion influx which are plausible candidates for mutation screening.