To evaluate the safety and efficacy of oxcarbazepine (OXC) as adjunctive therapy in children with inadequately controlled partial seizures on one or two concomitant antiepileptic drugs (AEDs).
OXC has shown antiepileptic activity in several comparative monotherapy trials in newly diagnosed patients with epilepsy, and in a placebo-controlled monotherapy trial in hospitalized patients evaluated for epilepsy surgery.
A total of 267 patients were evaluated in a multicenter, randomized, placebo-controlled trial consisting of three phases: 1) a 56-day baseline phase (patients maintained on their current AEDs); 2) a 112-day double-blind treatment phase (patients received either OXC 30-46 mg/kg/day orally or placebo); and 3) an open-label extension phase. Data are reported only from the double-blind treatment phase; the open-label extension phase is ongoing.
Children (3 to 17 years old) with inadequately controlled partial seizures (simple, complex, and partial seizures evolving to secondarily generalized seizures) were enrolled.
Patients treated with OXC experienced a significantly greater median percent reduction from baseline in partial seizure frequency than patients treated with placebo (p = 0.0001; 35% versus 9%, respectively). Forty-one percent of patients treated with OXC experienced a > or =50% reduction from baseline in partial seizure frequency per 28 days compared with 22% of patients treated with placebo (p = 0.0005). Ninety-one percent of the group treated with OXC and 82% of the group treated with placebo reported > or =1 adverse event; vomiting, somnolence, dizziness, and nausea occurred more frequently (twofold or greater) in the group treated with OXC.
OXC adjunctive therapy administered in a dose range of 6 to 51 mg/kg/day (median 31.4 mg/kg/day) is safe, effective, and well tolerated in children with partial seizures.
[Show abstract][Hide abstract] ABSTRACT: Despite guidelines establishing the need to perform comprehensive paediatric drug development programs, pivotal trials in children with epilepsy have been completed mostly in Phase IV as a postapproval replication of adult data. However, it has been shown that the treatment response in children can differ from that in adults. It has not been investigated whether differences in drug effect between adults and children might occur in the treatment of drug-resistant partial epilepsy, although such differences may have a substantial impact on the design and results of paediatric randomised controlled trials (RCTs).
Three electronic databases were searched for RCTs investigating any antiepileptic drug (AED) in the add-on treatment of drug-resistant partial epilepsy in both children and adults. The treatment effect was compared between the two age groups using the ratio of the relative risk (RR) of the 50% responder rate between active AEDs treatment and placebo groups, as well as meta-regression. Differences in the response to placebo and to active treatment were searched using logistic regression. A comparable approach was used for analysing secondary endpoints, including seizure-free rate, total and adverse events-related withdrawal rates, and withdrawal rate for seizure aggravation. Five AEDs were evaluated in both adults and children with drug-resistant partial epilepsy in 32 RCTs. The treatment effect was significantly lower in children than in adults (RR ratio: 0.67 [95% confidence interval (CI) 0.51-0.89]; p = 0.02 by meta-regression). This difference was related to an age-dependent variation in the response to placebo, with a higher rate in children than in adults (19% versus 9.9%, p < 0.001), whereas no significant difference was observed in the response to active treatment (37.2% versus 30.4%, p = 0.364). The relative risk of the total withdrawal rate was also significantly lower in children than in adults (RR ratio: 0.65 [95% CI 0.43-0.98], p = 0.004 by metaregression), due to higher withdrawal rate for seizure aggravation in children (5.6%) than in adults (0.7%) receiving placebo (p < 0.001). Finally, there was no significant difference in the seizure-free rate between adult and paediatric studies.
Children with drug-resistant partial epilepsy receiving placebo in double-blind RCTs demonstrated significantly greater 50% responder rate than adults, probably reflecting increased placebo and regression to the mean effects. Paediatric clinical trial designs should account for these age-dependent variations of the response to placebo to reduce the risk of an underestimated sample size that could result in falsely negative trials.
PLoS Medicine 09/2008; 5(8):e166. DOI:10.1371/journal.pmed.0050166 · 14.43 Impact Factor
"In particular, tiagabine has been shown to induce nonconvulsive status epilepticus in patients with lesional focal epilepsy (Ettinger et al., 1999; Vinton et al., 2005). Oxcarbazepine (OXC) is a new AED keto analog to CBZ (Kalis and Huff, 2001) that has demonstrated efficacy when used in monotherapy (Gaily et al., 1997; Kothare et al., 2006) or adjunctive regimen (Glauser et al., 2000) for patients with partial epilepsy. In several monotherapy trials, OXC has also been shown to be as efficacious as standard AEDs and much better tolerated then phenytoin and carbamazepine (Bill et al., 1997; Dam et al., 1989). "
[Show abstract][Hide abstract] ABSTRACT: Exacerbation of epilepsy may occur following initiation of therapy with antiepileptic drugs (AEDs). The aim of this study is to analyze the clinical and EEG characteristics of a group of pediatric patients with worsening of seizures and/or EEG deterioration while on oxcarbazepine (OXC).
A retrospective analysis of a clinical database was performed to identify patients with epilepsy treated with OXC over the past 3 years. History, neurological examination, and EEG findings were reviewed to identify any who had developed exacerbation of seizures or new abnormalities on EEG.
Of 290 patients on OXC, we identified 12 patients with new onset seizures, all with initial normal neurological exam and normal EEG, who developed either worsening of preexisting seizures, new seizure types, and/or EEG deterioration following introduction of OXC monotherapy. EEG changes were primarily characterized by new onset of generalized epileptiform activity not reported on the initial baseline EEG. Following substitution of OXC with a broad spectrum AED, significant improvement of seizure control and improvement in the EEG was observed.
These findings suggest that OXC can aggravate seizures and/or worsen EEG features in children. Following initiation of therapy with OXC, monitoring of patients with follow-up EEGs may be important, especially in patients who do not show adequate response to therapy.
") AED use 9 Optimal AED determined by given seizure type, seizure syndrome, and clinical circumstances (Epilepsy, 1998; Frank et al., 1999; Duchowny et al., 1999; Rating et al., 2000; Guerreiro et al., 1997; Glauser et al., 2000) 10 Side-effect profiles used when deciding on AED (Guerreiro et al., 1997) 11 AED monotherapy initiated first, as adequate for most pediatric epilepsy patients and preferable to polytherapy (Guerreiro et al., 1997; Frank et al., 1999; Rating et al., 2000; Epilepsy, 1998; Chiba et al., 1985; Arts et al., 2004) 12 Treatment initiated with a " first-line " monotherapy AED, unless specifically indicated Recommended AEDs: valproic acid (GTC, absence), oxcarbazepine (partial), carbamazepine (partial), ethosuximide (absence), phenobarbital (GTC <2 yr of age) (Glauser et al., 2000; Sato et al., 1982; Chiba et al., 1985) AED monitoring 13 Routine blood and/or urine monitoring of monotherapy AED not indicated when a standard dose results in complete seizure control without side effects c 14 AED levels monitored when likely to be helpful (Camfield et al., 1985) AED side effects 15 Family informed about potential common or serious side effects of specific AED prescribed, outlining plans to monitor (Clusmann et al., 2004; Aman et al., 1994; Wheless et al., 2004; Verrotti et al., 2004) AED discontinuation 16 Information about epileptiform EEG, abnormal neurologic findings, age at onset, and other risk factors for poor outcome used in decisions about AED discontinuation (Arts et al., 1999; Shinnar et al., 1994; Todt, 1984; Arts et al., 2004) 17 A 2-yr seizure-free interval before considering AED discontinuation, unless indicated by special circumstances (Shinnar et al., 1985; Shinnar et al., 1994; Arts et al., 2004) Cognitive issues 18 Educational progress monitored to assess for academic difficulties (Vermeulen et al., 1994; Chen et al., 1996) 19 Evaluation recommended when attention and concentration problems arise with epilepsy or AED treatment (Croona et al., 1999; Aman et al., 1994; Borgatti et al., 2004) 20 Parents of children with ADHD advised that treatment with stimulant medication is not contraindicated in children with epilepsy (Gucuyener et al., 2003) Behavioral issues 21 Behavioral status monitored at initial evaluation and when risk factors are present (Austin et al., 2001; Oostrom et al., 2001; Lendt et al., 2000; Camfield et al., 2003) 22 Careful history taken regarding psychosocial problems (especially depression and social problems) at initial visit, when risk factors are present, when seizure control is poor (Oostrom et al., 2000; Ronen et al., 2003; Caplan et al., 2004) 23 Parents/families instructed when to monitor for behavioral side effects associated with AED use "
[Show abstract][Hide abstract] ABSTRACT: To use available evidence and expert consensus to develop performance indicators for the evaluation and management of pediatric epilepsy.
We used a three-step process to develop the performance indicators. First, research findings were compiled into evidence tables focusing on different clinical issues. Second, an advisory panel of clinicians, educational and public health experts, and families of children with epilepsy reviewed the evidence. The advisory group used the evidence to draft a preliminary set of performance indicators for pediatric epilepsy management. Third, 13 internationally recognized experts in pediatric neurology or epilepsy rated the value of these indicators on a 5-point scale [1 (essential) to 5 (not necessary)] in a two-round Delphi process. Positive consensus was reached if >or=80% of experts gave an indicator a "1" rating and negative consensus if >80% gave an indicator a "5" rating. Indicators that achieved positive consensus during either round of the Delphi process constituted the final set of indicators.
Of the 68 draft performance indicators, the expert panel members achieved positive consensus on 30 performance indicators: eight indicators related to diagnostic strategies and seizure classification, nine related to antiepileptic drug use, six related to cognitive and behavioral issues, six related to quality of life, and three related to specialty referrals.
We identified 30 potential indicators for evaluating the care provided to pediatric patients with epilepsy. The next step is to examine the relation of these performance indicators to clinical outcomes and health care utilization among pediatric patients with epilepsy.
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