Seizure Management Quality Care for Our Patients

Transcription

1 Seizure Management Quality Care for Our Patients

2 Case 6 Jack Pellock, MD 8 year old female with refractory epilepsy Multiple handicaps, developmental delay Cerebral palsy spastic diplegia but ambulatory History of infantile spasms response to ACTH Seeking second opinion as family has moved recently JP

3 Case 8 year old female with DD and refractory epilepsy Seizure type is poorly described but: Drop spells, sometimes falls Convulsions unsure if both or either side Staring into space: recovery sometimes takes a few minutes Sometimes stiffens with tremors, mostly during sleep Some days seems to be in a daze for hours, blinking and starring Multiple episodes of status epilepiticus and seizure clusters

4 Case 8 year old female with DD and refractory epilepsy Prior records: treated with 8 AEDs in the past Currently on LEV, VPA, CBZ Imaging studies 6 years ago -? Generalized atrophy, no lesion Differential diagnosis: encephalopathic epilepsy CBZ added for convulsions Now back to old pattern,?more drops Unsure if VPA or LEV is helping, but seemed to once

5

6 LGS Defined by International League Against Epilepsy (2001) Childhood onset Multiple seizure types usually refractory Common: tonic, atonic, atypical absence Rare: focal, myoclonic Specific EEG pattern Diffuse SSW complexes and bursts of fast rhythms ( 10 Hz) during sleep Psychologic abnormalities with psychomotor delay, behavioral disorder, or both Engel J, et al. Epilepsia. 2001;42:

7 Arzimanaglou A, et al. Lancet Neurol. 2009;8:82-93; Borggraefe I, Noachtar S. Clin Med Insights Ther. 2010;2: Multiple Seizure Types Seizure Type Tonic Features Most common/characteristic seizure type (occurring in 17%-95% of cases) Prerequisite for LGS diagnosis Sustained increase in muscle contraction lasting a few seconds to minutes Observed mainly during sleep Atypical absence Sudden tonic or atonic falls ( drop attacks ) Non-convulsive status epilepticus* Myoclonic* Other* Second most common seizure type Term used for any seizure associated with brief loss/lapse of consciousness Level of consciousness difficult to determine in severely retarded patients Typically preceded by brief myoclonic jerk Also observed in other epilepsy syndromes not always evolving to LGS Presence of drop attacks is not diagnostic of LGS Occur in 50%-75% of LGS patients Subcontinuous atypical absences with varying degrees of consciousness, periodically interrupted by brief tonic seizures Occur in many generalized epilepsy syndromes (not a defining feature) Seizure shorter (<100 ms) than tonic events; can also result in falls Focal with/out secondary generalization, GTC, unilateral clonic Normally present in later stages of LGS, but sometimes precede core seizures Red box = core seizure types in children (childhood onset). *Older LGS patients are more likely to have these seizure types, especially secondarily GTC.

8 Epidemiology of LGS Accounts for 1%-10% of all childhood epilepsies 1 May evolve from infantile spasm and encephalopathic epilepsy IS preceded LGS in 39% of cases 2 Annual incidence of LGS: 2 per 100,000 individuals 2 Prevalence ranges from per 1000 individuals 2 Onset <8 yrs of age (peak 3-5 yrs) 3,4 More common in males than females 4 Seizures persist throughout life in >80% of cases 4 1. Crumrine P. Paediatr Drugs. 2011;13: ; 2. Trevethan E, Murphy CC. Epilepsia. 1997;38: Arzimanaglou A, et al. Lancet Neurol. 2009;8:82-93; 4. Van Rijkevorsel K. Neuropsych Dis Treat. 2008;4:

9 Diagnostic Workup Complete medical history Detailed physical / neurologic exam Family history Routine blood work, toxic screening, metabolic monitoring*, serum levels EEG (often requires sedation in multiply handicapped) Neuro-imaging (MRI preferred) Video-EEG monitoring Video recording of events * Consider metabolic monitoring in multiply handicapped patients who may not be able to express symptoms

10 Case 8 year old female with DD and refractory epilepsy Your plan: Diagnosis and treat Patient needs: No seizures I m drugged Too many ED visits Fewer injuries Family needs: Diagnosis and prognosis At home therapy New treatments Daily care Is there any hope? (injuries, death)

11 Medication Changes?

12 Median Reduction in Drop Attacks with AEDs in LGS* 80 Active Placebo P <.0001 Percent reduction P =.002 P =.01 P =.041 P < Felbamate 1 Lamotrigine 2 Topiramate 3 Rufinamide 4 Clobazam 5 high dose (1.0 mg/kg/day) *Results are from individual studies. AEDs are listed from left to right by FDA approval date. 1 The Felbamate Study Group. N Engl Med. 1993;328:29-33; 2 Motte J, et al. N Engl J Med. 1997;337: ; 3 Sachdeo RC, et al. Neurology. 1999;52:1882-7; 4 Glauser T, et al. Neurology. 2008;70: ; 5 Ng YT, et al. Neurology. 2011;77:

13 Median Reduction in Total Seizure Frequency with AEDs in LGS* 70 Active Placebo P <.0001 Percent reduction P <.001 P =.002 P =.0015 P = NS Felbamate 1 Lamotrigine 2 Topiramate 3 Rufinamide 4 Clobazam 5 high dose (1.0 mg/kg/day) *Results are from individual studies. AEDs are listed from left to right by FDA approval date. 1 The Felbamate Study Group. N Engl Med. 1993;328:29-33; 2 Motte J, et al. N Engl J Med. 1997;337: ; 3 Sachdeo RC, et al. Neurology. 1999;52:1882-7; 4 Glauser T, et al. Neurology. 2008;70: ; 5 Ng YT, et al. Neurology. 2011;77:

14 Cochrane Review of All RCTs of AEDs in LGS Review included 9 RCTs No meta-analysis performed due to Different trial populations, therapies, and outcomes Results/Conclusions Ideal treatment for LGS remains uncertain No study has shown one drug to be highly efficacious Rufinamide, lamotrigine, topiramate, and felbamate may be useful as add-on therapy Clobazam may be helpful for drop seizures Hancock EC, Cross JH. Cochrane Database Syst Rev. 2013; Feb 28;2:CD

15 Treatment Approaches Pharmacotherapy Antiepileptic drugs (AEDs) Non-pharmacotherapy Diet Ketogenic Modified Atkins Surgery Vagus nerve stimulation (VNS) Corpus callosotomy Arzimanaglou A, et al. Lancet Neurol. 2009;8: Borggraefe I, Noachtar S. Clin Med Insights Ther. 2010;2: Kerr M, et al. Epileptic Disord. 2011;13:S Lemmon ME, Kossoff EH. Curr Treat Options Neurol. 2013;6:

16 Vagus Nerve Stimulation (VNS) Pulse generator implanted subcutaneously and connected to left vagus nerve 1 Stimulation parameters can be programmed Approved as adjunctive therapy for patients aged 12 yrs with refractory partialonset seizures Evidence-based guidelines recommend VNS for LGSassociated seizures 2 Figure from 1 Sethi NK, et al. The Internet J Neurol. 2008;9. 2 Morris GL, et al. Neurology. 2013;81:1-7.

17 Efficacy and Safety of VNS in LGS Efficacy Possibly effective in achieving seizure frequency reduction in LGS Author N Age (yrs) Median Reduction in All Seizure Types (%) Safety Most common AEs (in >20% of patients) Hoarseness, increased coughing, paresthesia, pharyngitis 6 50% Seizure Frequency Reduction (%) Hosain et al, Frost et al, Majoie et al, Shahwan et al, Kostov et al, Hosain S, et al. J Child Neurol. 2000;15: ; 2 Frost M, et al. Epilepsia. 2001;42: ; 3 Majoie H, et al. Seizure. 2005;14:10-18; 4 Shahwan A, et al. Epilepsia. 2009;50: ; 5 Kostov K, et al. Epilepsy Behav. 2009;16: ; 6 Cyberonics, Inc. VNS Therapy System Physician s Manual, January 2014.

18 Corpus Callosotomy (CC) CC entails sectioning of either anterior two-thirds only or entire corpus callosum 1,2 Partial: better speech preservation Complete: better seizure control CC effective for treating drop attacks, absence, GTCS %-85% of pts achieve >80% reduction in drop attacks 2,3 VNS often considered first due to invasive nature and risk of AEs with CC 1 Figure from 1 VanStraten AF, Ng Y-T. Pediatr Neurol. 2012;47: Maehara T, et al. Epilepsia. 2001;42: Nei M, et al. Epilepsia. 2006;47: Asadi-Pooya AA, et al. Epilepsy Behav. 2013;29:

19 Meta-Analysis: CC vs VNS in LGS Analysis included 17 VNS and 9 CC studies CC more effective than VNS in reducing atonic seizures >50% reduction: 80% vs 54%, P < 0.05 >75% reduction: 70% vs 26%, P < 0.05 Patients who underwent CC more likely to be free of atonic seizures (48% vs 23%, P = NS) VNS comparable to CC for all other seizure types (tonic, GTC, complex partial, myoclonic) Lancman G, et al. Seizure. 2013;22:3-8.

20 Ketogenic Diet Should be considered early in treatment course Ketogenic diet consists of meals that are 3:1 or 4:1 fat: carbohydrate plus protein grams Children admitted to hospital for 3-4d to begin diet Glucose and urine ketones monitored during this time Rigid compliance essential VanStraten AF, Ng Y-T. Pediatr Neurol. 2012;47: Lemmon ME, Kossoff EH. Curr Treat Options Neurol. 2013;15:

21 Efficacy of Ketogenic Diet in LGS Efficacy Ketogenic diet is efficacious in the treatment of LGS Author N Age (yrs) >50% Reduction in Seizure Frequency >90% Reduction in Seizure Frequency Freeman et al, Lemmon et al, Results were similar after 12 months Limitations Treatment noncompliance may be worse with ketogenic diet due to its restrictive and complicated nature 1 Freeman JM, et al. Epilepsia. 2009;50: Lemmon ME, et al. Dev Med Child Neurol. 2012;54:

22 Lennox-Gastaut Syndrome LGS remains one of the most challenging epileptic encephalopathies despite availability of several new AEDs 1 Long-term outcome regarding seizure control and intellectual development is disappointing and can be taxing for families 2 Management of LGS into adulthood requires global care approach 3 Offers unique challenges regarding recognition and diagnosis Total seizure control not necessarily the main concern as management of comorbidities is often a higher priority 3 Coordinate educational and psychosocial needs with medical care 1 Arzimanaglou A, et al. Lancet Neurol. 2009;8: Camfield PR. Epilepsia. 2011;52: Kerr M, et al. Epileptic Disord. 2011;13:S15-26.

23 Prognosis Poor long-term prognosis due to uncontrolled seizures 1,2 Refractory epilepsy with multiple seizure types persists in many LGS patients from childhood through adulthood 1,3 Worse prognosis in patients with symptomatic LGS (mainly with preexistent infantile spasms/west syndrome), frequent seizures, and repeated status epilepticus episodes 4 High and variable mortality rate 5-8 SUDEP accounts for up to 50% of deaths 6 3%-7% largely related to accidents 7 25% due to underlying neurologic conditions 8 Frequent falls with fracture (hip) or closed head injury 1 Markand ON. J Clin Neurophysiol. 2003;20:426-41; 2 Ferrie CD, Patel A. Eur J Paediatr Neurol. 2009;13: ; 3 Crumrine PK. J Child Neurol. 2002;17:S70-75; 4 Campos-Castelló J. Orphanet Encyclopedia. 2004: Van Rijkevorsel K. Neuropsych Dis Treat. 2008;4: ; 6 Sperling MR. CNS Spectr. 2004;9:98-101, Glauser TA. Epilepsia. 2004;45(S5):23-6; 9 Camfield P, Camfield C. Epilepsia. 2007;48: