Presentation on theme: "Advances in the Treatment of Epilepsy"— Presentation transcript:
1 Advances in the Treatment of Epilepsy Olgica Laban-Grant, MDNortheast Regional Epilepsy Groupepilepsygroup.com
2 Epilepsy Epilepsy is one of the most common neurological diseases. It affects all ages, races & ethnic backgroundsIt affects approximately 0.5-2% of the population (2.7 million Americans).Every year, approximately 200,000 people develop epilepsy
3 SeizuresUp to 5% of the population may have a single seizure at some time in their lives.Seizures may be symptom of different disorders
4 SeizuresThe healthy brain consists of millions of interconnecting nerve cells called neurons.Neurons are constantly communicating with each other by sending signals through tentacle-like connections called axons and dendrites
7 Seizures Neurons normally generate impulses up to 80 times a second. During an epileptic seizure, that rate can increase to up to 500 times a second.
8 What Is Epilepsy?Epilepsy is the term applied to the state of recurrent seizures.If you had two seizures there is 80% chance you will have more.Epilepsy is usually diagnosed when person had at least two seizures that were not caused by known medical condition.
9 Single seizure Recurrent seizures 5-10% 0.5-2% Seizure vs. EpilepsySingle seizure Recurrent seizures 5-10% %
10 Why EEGEEG as predictor of the risk of recurrence within two years of first seizureepileptic discharges - 83%nonepileptic abnormalities -41%Normal – 12%
11 EpilepsyEpilepsy is a tremendously variable condition in terms of its cause, seizure types and response to treatment.
12 Trteatment Depends on many factors: Age Type of seizures Type of epilepsyMedical historyFrequency and severity of seizuresAvailable drug formulations of medications
13 Treating Epilepsy The goal in treating epilepsy is No seizures No side effects
14 Treating Epilepsy First line treatment is medication Surgery and surgical devicesDietLifestyle (avoiding trigger factors)
15 MedicationsMedications do not cure epilepsy, rather they control epilepsy by suppressing the seizures.
16 MedicationsBrain function is result of fine balance of activation and suppression of neuron activity.Balance is maintained by chemicals in brain called neurotransmitters.Medications are designed to reestablish balance among chemicals in brain.
17 AED Therapy Trial and Error Method Epilepsy Time First AED Increase DosageSwitchAEDCombineAEDsPolytherapyTrial and Error Method17
18 Response to AEDs PharMetrics. April 2002 to June 2003 IMS NPA, Dec 2003.Kwan P, Brodie MJ. N Engl J Med 2000; 342:18
19 Combine medications with different mechanism of action
22 Lacosamide (Vimpat) FDA approved in 2008 Epilepsy treatment for partial-onset seizures in patients who are 17years and older.It is a medication that can be added to any other antiseizure medication
23 Partial (Focal) Seizures Generalized Seizures International League Against Epilepsy (ILEA) Classification of SeizuresPartial (Focal) SeizuresSimple PartialComplex PartialGeneralized SeizuresAbsenceMyoclonicClonicTonicTonic-ClonicAtonic
24 Partial Seizures Simple Partial: No impairment of consciousness. Complex Partial: Altered awareness
25 Lacosamide (Vimpat)Approximately 40% of patients in clinical studies had their partial-onset seizures reduced by half or more.More seizure-free days
26 Lacosamide (Vimpat) Mechanism of action Enhances the number of sodium channels entering into the slow inactivated state Does not affect activity mediated by fast inactivation
32 Lacosamide (Vimpat) Side effects Depression 1:500 Dizziness, double vision, sleepiness, problems with coordinationIrregular heartbeat (may prolong PR interval on EKG)No effect on weightNo effect on memory
33 Banzel (Rufinamide) FDA approved in 2008 Indicated for add on treatment of seizures associated with Lennox-Gastaut syndrome in children 4 years and older and adults.
34 Lennox-Gastaut syndrome 1-4% of childhood epilepsiesDifferent types of seizures (tonic, atonic, myoclonic, generalized seizures)Mental retardationSpecific EEG patternDifficult to treat
35 Banzel (Rufinamide) reduction in total seizure number 42.5% median percentage reduction in tonic-atonic seizure (drop attack)significant improvement in seizure severity
36 Banzel (Rufinamide)Reports on decrease of frequency of partial seizures –medication is not approved for this indication.Total partial seizures were reduced by 23.3% rufinamide and by 9.8% with placebo (86% were taking at least two drugs)
37 Banzel (Rufinamide) The exact mechanism of action is unknown. Modulates the activity of sodium channels and, in particular, prolongation of the inactive state of the channel.
38 Banzel (Rufinamide) Side effects Depression 1:500 Dizziness, double vision, sleepiness, problems with coordinationMay make the contraception less effectiveIt is contraindicated in familial short QT syndrome-EKG prior to starting it
39 Sabril (Vigabatrin) FDA approved in 2009 Refractory complex partial seizuresInfantile spasms (IS) - babies between the ages of 1 month and 2 years
40 Infantile spasms Onset typically 4-8 months infantile spasms developmental regressionspecific pattern on EEG called hypsarrhythmia (chaotic brain waves)
41 Sabril (Vigabatrin) Mechanism of action Preventing breaking down of GABA. GABA is chemical that suppresses activity in neurons.
43 Sabril (Vigabatrin) Side effects It may permanently damage the vision. The most noticeable loss is in the ability to see to the side when looking straight ahead (peripheral vision).Occurred in 30% or more of patient.
44 Ezogabine (Potiga)Adjunctive therapy in partial-onset seizures uncontrolled by current medications in adultsFDA approved in 2011 but not available yet in USA
45 Ezogabine (Potiga)Novel mechanism of actionPotassium channel opener
46 Ezogabine (Potiga) Side effects dizziness, fatigue, tremor, problems with coordination, double visionmemory impairmentlack of strength.urinary retentionconfusion, hallucinationsdepression
48 The Ketogenic DietA medically prescribed, strict dietary regimen used for the refractory pediatric patient
49 Ketogenic Diet Mimics the metabolic effects of starvation Used primarily to treat severe childhood epilepsy that has not responded to standard antiseizure drugsDiet includes high fat content, no sugar and low carbohydrate and protein intake
50 The Ketogenic diet side effects Dehydration, constipation, kidney stones or gall stones, pancreatitis, decreased bone density, menstrual irregularities.vitamins have to be added through supplements.
51 Diet in adultsKetogenic diet is not typically offered to adults with epilepsy due to the significant lifestyle alterations needed for its useA modified Atkins diet appears to demonstrate preliminary efficacy for adults with intractable epilepsy, especially in those who lost weight.
52 Modified Atkinsallowance of more carbohydrates than in ketogenic diet but less than in Atkins diet (10-20g)More fat than in Atkins diethigh-protein dietno caloric or fluid restrictionsno weighing or measuring of foodsno admission fast is required
53 Goals of Epilepsy Surgery To eradicate or significantly reduce the amount and severity of seizuresTo minimize the disability secondary to seizuresTo address quality of life issuesTo decrease medication
54 Surgical devices Vagus Nerve Stimulator Deep Brain Stimulation Neuropace
55 Surgical devices Vagus Nerve Stimulator Deep Brain Stimulation Neuropace
56 Deep Brain stimulation stimulating electrode is implanted in the brain (anterior nuclei of thalamus)56% reduction in seizure frequencyFDA approved for patients with severe and refractory partial seizures
57 Neuropaceresponsive neurostimulator which is implanted in the brain, detects abnormal electrical activity and sends out electrical impulses to prevent seizuresClinical trials started