SUDEP: Minimizing Risk

Transcription

1 SUDEP: Minimizing Risk ELIZABETH J. DONNER, MD, MSC, FRCPC THE HOSPITAL FOR SICK CHILDREN UNIVERSITY OF TORONTO

2 Learning Objectives 1. Evaluate SUDEP risk 2. Consider strategies SUDEP prevention 3. Discuss SUDEP with their colleagues and patients.

3 Seizure onset 6 months Nathan Multiple seizure types Dravet Syndrome Oxcarbazepine, Clobazam, Stiripentol, Topiramate Age 4 focal motor face seizures Mild developmental delays Weaning Topiramate

4 Jordan Developmentally normal, excellent student, athlete Seizure onset age 14 Rare convulsive and very rare myoclonic VPA related adverse effects Compliant with lamotrigine

5 Practice Guideline Sudden Unexpected Death in Epilepsy Incidence Rates and Risk Factors 2016 American Academy of Neurology Report by: Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Epilepsy Society

6 Clinical Questions Clinical Question 1 What is the incidence rate of SUDEP in different epilepsy populations? Clinical Question 2 Are there specific risk factors for SUDEP? 2016 American Academy of Neurology

7 Conclusions for SUDEP incidence Population SUDEP/1,000 Confidence level patient-years (CI) Overall 0.58 ( ) Low Childhood 0.22 ( ) Moderate Adulthood 1.2 ( ) Low 2016 American Academy of Neurology Slide 7

8 SUDEP may be more common in children than previously documented Definite and Probable SUDEP Incidence per 1000 patient years All ages 1.2 ( ) < 16 years 1.11 ( ) Sveinsson, et al Neurology 2017

9 17 SUDEP deaths over 2 years 11 definite, 3 probable, 2 definite plus, and 1 near plus 10/17 (59%) male Incidence 1.11 (0.63, 1.79) per 1000 per year

10 SUDEP is more Common in Children than Previously Documented Definite and Probable SUDEP Incidence/1000 patient-years All ages (Sweden) 1.2 ( ) < 16 years (Sweden) 1.11 ( ) <18 years (Ontario, Canada) 1.1 ( ) years (Sweden) > 50 years (Sweden) 1.13 ( ) 1.29 ( ) Sveinsson, et al Neurology 2017; Keller, et al Neurology, 2018

11 Circumstances of Death Death in bed, prone 10-20% witnessed death 50 to 90% with evidence of a convulsive seizure immediately preceding death Witnessed SUDEP more common in children 10/27 witnessed 5/10 convulsive seizure Nocturnal supervision may be protective Nashef, et al. 1995; Donner, 2001; Langan, Nashef et al. 2005; Donner, 2011

12 Risk factors ILAE combined analysis of 289 cases of definite or probable SUDEP and 958 living controls Stratified by age at epilepsy onset Frequent GTC Polytherapy Younger age of epilepsy onset 3 GTC per year and polytherapy increases risk 12.8 times in people with epilepsy onset 16 yrs 37.4 times in those with epilepsy onset <16 yrs Hesdorffer, et al. 2010

13 Adjusting for number of GTC No increased risk associated with AED monotherapy, AED polytherapy or any individual AED

14 33 deaths (18 SUDEP) from 112 eligible randomized trials Rates of definite or probable SUDEP 0 9 per 1000 person-years in patients who received efficacious AED doses (95% CI ) 6 9 per 1000 person-years ( ) in those allocated to placebo.

15 Most concerning risk factors Factor Odds ratio (CI) Confidence level Presence of GTCS vs lack of GTCS Frequency of GTCS 10 (7 14) Moderate OR 5.07 ( ) for 1 2 GTCS per y, and OR ( ) for >3 GTCS per y High Not being seizure free for 1 5 y 4.7 (1.4 16) Moderate Not adding an AED when patients are medically refractory Nocturnal supervision (risk reduction) Use of nocturnal listening device (risk reduction) 6 (2 20) Moderate 0.4 ( ) Moderate 0.1 ( ) Moderate 2016 American Academy of Neurology Slide 15

16 Expecting the unexpected Who is most at risk? Highest risk: Early onset epilepsy Refractory GTC seizures Lack of nocturnal supervision

17 Plan for SUDEP risk reduction Active epilepsy management: 1. Seizure reduction, particularly GTC reduction, is the most important treatment goal 2. Treatment adherence 3. Identify and avoid triggers for seizures 4. Use of a nocturnal listening device when feasible 5. Consider other epilepsy treatments when medications are not sufficient to control seizures

18 Talking about SUDEP 2008 AES Task Force report The potentially increased risk of death associated with epilepsy should be disclosed in the context of a comprehensive education program The risk of SUDEP may need to be emphasized to encourage compliance with medical therapy or consideration of epilepsy surgery. SUDEP discussion can be reassuring to patients whose epilepsies are associated with very low SUDEP risk Institute of Medicine Report To manage fears and prevent unnecessary anxiety, people with epilepsy and their families need complete and accurate information about the comorbidities and mortality risks associated with epilepsy, SUDEP

19 2017 AAN Recommendations 1. Inform parents there is a rare risk of SUDEP In 1 year, SUDEP typically affects 1 in 4,500 children with epilepsy; in other words, annually, 4,499 of 4,500 children will not be affected by SUDEP 2. Inform adult with epilepsy that there is a small risk of SUDEP In 1 year, SUDEP typically affects 1 in 1,000 adults with epilepsy; in other words, annually, 999 of 1,000 adults will not be affected by SUDEP 3. Inform persons with epilepsy that seizure freedom, particularly freedom from GTCS (which is more likely to occur with medication adherence), is strongly associated with a decreased risk of SUDEP

20 People with epilepsy want to know more 44-62% of adults with epilepsy and 83-94% of caregivers are worried the person with epilepsy may die of epilepsy ~ Google searches for SUDEP from % increase from 2004 to 2013 for the search term epilepsy SUDEP But are unclear of risk 44% of adults with epilepsy are unsure of their risk 35% of caregivers believe the person with epilepsy is not at risk 34% of surveyed UK parents already knew of SUDEP; 91% wanted to know more Kroner, et al, 2014; Gayatri, 2010; RamanchandranNair, 2013; Brigo, 2014; Prinjha, 2005

21 Ethical considerations Consistent with principles of autonomy Truth telling is preserved Prevention of harm Allows for natural psychological adaptation Worries about catastrophic psychological harm and worsening of quality of life are unfounded Nancy S. Collins, PAME, 2014

22 How often is SUDEP discussed? p e rc e n t some mes rarely or never all or majority UK: Morton, 2006 Italy: Vegni, 2011 NA: Freidman, 2014

23 Who does discuss SUDEP? Neurologists with >100 epilepsy patients seen annually were 2 times more likely to discuss (OR 2.01, 95% CI , p = 0.008) Neurologists with a SUDEP death in previous 24 months were 2.3 times more likely to discuss. (OR 2.27, 95% CI: , p < 0.01) Neurologists with better knowledge regarding SUDEP more often discuss it with their patients Freidman, et al., 2014

24 Opportunities for SUDEP Discussion At diagnosis When asked Seizure freedom / drug discontinuation Poor adherence Lifestyle changes / milestones Diagnosis of intractable seizures Surgical referral

25 Education is the most accessible tool we have to reduce the burden of mortality in epilepsy. IT IS TIME TO TALK ABOUT SUDEP 25

26 Resources

27 Hadyen Eric Jordan Lisa Henry