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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


New Onset Epilepsy: Emerging Trends and Strategies for Improving Outcomes


GOAL
To provide neurologists with current information on epilepsy therapy.

TARGET AUDIENCE
This activity is designed for neurologists. No prerequisites required.

LEARNING OBJECTIVES
The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity. At the conclusion of this activity, participants should be able to:

  • Determine the appropriate time to initiate antiepileptic drug therapy in patients with new-onset epilepsy.
  • Identify patients who are at high risk for epilepsy and determine appropriate management of these patients.
  • Evaluate the evidence from pharmacotherapy trials on monotherapy, and understand how to use an evidence-based approach for pharmacologic management of patients.
  • Understand the pharmacologic treatment considerations in patients with new-onset epilepsy, including long-term use, and weight gain.
  • Compare monotherapy versus polytherapy after initial diagnosis and treatment in patients with epilepsy.
  • Understand when and how to ÒswitchÓ therapies in patients with epilepsy.

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 category 1 credits toward the AMA Physician's Recognition Award. Each physician should claim only those credits that he/she actually spent in the activity. The estimated time to complete this educational activity:  2 hours.

Release date: January 15, 2005.
Expiration date: January 15, 2007.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of Johns Hopkins University School of Medicine name implies review of educational format, design, and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an educational grant from Ortho-McNeil Pharmaceutical, Inc.

Full Disclosure Policy Affecting CME Activities:
As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Directors and Participating Faculty reported the following:

PROGRAM DIRECTORS

Nathan Crone, MD
Assistant Professor of Neurology
Division of Cognitive Neurology
Johns Hopkins University School of Medicine
Baltimore, Maryland
Dr Crone reports having no significant financial or advisory relationships with corporate organizations related to this activity.

Peter W. Kaplan, MBBS, FRCP
Professor of Neurology
Johns Hopkins University School of Medicine
Chairman of Neurology
Director, Epilepsy and EEG Program
Johns Hopkins Bayview Medical Center
Baltimore, Maryland
Dr Kaplan reports receiving grants/research support from GlaxoSmithKline, Marion Merrill Dow, Inc, Pfizer Inc, and UCB Pharma; serving as a consultant to Abbott Laboratories, Elan Corporation, GlaxoSmithKline, Novartis Pharmaceuticals USA, Ortho-McNeil Pharmaceutical, Inc, Pfizer Inc, and UCB Pharma; and serving on the speakerÕs bureaus for Abbott Laboratories, GlaxoSmithKline, Novartis Pharmaceuticals USA, Pfizer Inc, and UCB Pharma.

PARTICIPATING FACULTY

E. Martina Bebin, MD
Associate Professor
Department of Neurology
University of Alabama
North Alabama Children's Specialists - Huntsville
Huntsville, Alabama
Dr Bebin reports receiving grants/research support from UCB Pharma, and serving as a consultant to GlaxoSmithKline, Novartis Pharmaceuticals USA, and Ortho-McNeil Pharmaceutical, Inc.

Dennis J. Dlugos, MD
Assistant Professor of Neurology
University of Pennsylvania
Division of Neurology
The Children's Hospital of Philadelphia
Philadelphia, Pennsylvania
Dr Dlugos reports serving as a consultant to Abbott Laboratories, GlaxoSmithKline, Novartis Pharmaceuticals USA, and Ortho-McNeil Pharmaceutical, Inc; and receiving honoraria from Abbott Laboratories, Cyberonics, Inc, Elan Corporation, GlaxoSmithKline, Novartis Pharmaceuticals USA, and Ortho-McNeil Pharmaceutical, Inc.

Frank Gilliam, MD
Caitlin Tynan Doyle Professor of Neurology
Head, Epilepsy Division
Director, Comprehensive Epilepsy Center
Columbia University
New York, New York
Dr Gilliam reports receiving grants/research support from and serving as a consultant to Elan Corporation, GlaxoSmithKline, Ortho-McNeil Pharmaceutical, Inc, and UCB Pharma; and receiving honoraria from Elan Corporation, GlaxoSmithKline, Novartis Pharmaceuticals USA, Ortho-McNeil Pharmaceutical, Inc, and UCB Pharma.

Tracy Glauser, MD
Director of the Children's Comprehensive Epilepsy Program
Director of the Drug TrialsProgram for Neurologic Disease
Children's Hospital Medical Center
Cincinnati, Ohio
Dr Glauser reports receiving grants/research support from Abbott Laboratories, Eisai Inc, Elan Corporation, GlaxoSmithKline, Johnson & Johnson, Novartis Pharmaceuticals USA, Pfizer Inc, and UCB Pharma; serving as a consultant to Abbott Laboratories, Eisai Inc, Elan Corporation, GlaxoSmithKline, Janssen-Cilag, MedPointe Pharmaceuticals, Novartis Pharmaceuticals USA, Ortho-McNeil Pharmaceutical, Inc, Pfizer Inc, Shire Pharmaceuticals Group, UCB Pharma, and Xcel Pharmaceuticals, Inc; and receiving  honoraria from Eisai Inc, Elan Corporation, GlaxoSmithKline, Janssen-Cilag, MedPointe Pharmaceuticals, Novartis Pharmaceuticals USA, OrthoMcNeil Pharmaceutical, Inc, Pfizer Inc, Shire Pharmaceuticals Group, UCB Pharma, and Xcel Pharmaceuticals, Inc.

Georgia D. Montouris, MD
Assistant Professor of Neurology
Boston University School of Medicine
Associate Director of Epilepsy Services
Epilepsy Center
Boston University Medical Center
Boston, Massachusetts
Dr Montouris reports receiving grants/research support from Schwarz Pharma and UCB Pharma; serving as a consultant to Abbott Laboratories, Elan Corporation, GlaxoSmithKline, Ortho-McNeil Pharmaceut-ical, Inc, Pfizer Inc, and UCB Pharma; and receiving honoraria from Cyberonics, Inc, GlaxoSmithKline, Novartis Pharmaceuticals USA, Ortho-McNeil Pharmaceutical, Inc, Pfizer Inc, and Xcel Pharmaceuticals, Inc. Dr Montouris also holds stock in Johnson & Johnson and Merck & Co, Inc.

R. Eugene Ramsay, MD
Professor of Neurology and Psychiatry
International Center for Epilepsy
University of MiamiSchool of Medicine
Miami, Florida
Dr Ramsay reports receiving grants/research support from Abbott Laboratories, Bertek Pharmaceuticals, Inc, Carter Wallace, Inc, Cephalon, Inc, Cyberonics, Inc, Dainippion Pharmaceutical Co, Ltd, Eisai Inc, GlaxoSmithKline, Marion Merrill Dow, Inc, Novartis Pharmaceuticals USA, Ortho-McNeil Pharmaceutical, Inc, Ovation Pharmaceuticals, Inc, Pfizer Inc, the Robert Wood Johnson Foundation, UCB Pharma, and Xcel Pharmaceuticals, Inc; serving as a consultant to Abbott Laboratories, Bertek Pharmaceuticals, Inc, Cyberonics, Inc, Eisai Inc, GlaxoSmithKline, IVAX Corporation, Novartis Pharmaceuticals USA, Ortho-McNeil Pharmaceutical, Inc, Pfizer Inc, and UCB Pharma. Dr Ramsay also holds stock in Pfizer Inc.

Notice: In accordance with the ACCME Standards for Commercial Support, the audience is advised that one or more articles in this continuing medical education activity may contain reference(s) to unlabeled or unapproved uses of drugs or devices. The following faculty members have disclosed that they have referenced the following unlabeled/unapproved uses of drugs or devices:

Dr Dlugos—carbamazepine, gabapentin, lamotrigine, levetiracetam, phenobarbital, phenytoin, primidone, tigibine, topiramate, valproate, zonisamide.
Dr Gilliam—carbamazepine, lamotrigine, phenobarbital, phenytoin, primidone, topiramate.

All other faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

New-Onset Epilepsy: Emerging Trends And Strategies For Improving Outcomes
Peter W. Kaplan, MBBS, FRCP* and Nathan Crone, MD 

Epilepsy affects approximately 0.5% to 0.7% of the population with a cumulative incidence that approaches 2% to 3% during a patient's lifetime. These patients have clearly benefited from the newer antiepileptic agents that have been developed since 1994. In addition, a number of new technologies including vagal nerve stimulation, which has now been established as an effective treatment, show us that more progress is being made. Pioneering work involving deep brain stimulation is ongoing and recent data indicate that surgery may be a treatment of choice that should be considered earlier than it has been in the past.

With increased understanding and improved management of epilepsy and its comorbidities, we have increasing responsibility to inform patients and the public of this evolving knowledge. We need to address the needs of our patients including their social issues and their more immediate physical concerns. Epilepsy and its treatment carry cognitive burdens and newer data suggests that some enzyme-inducing and enzyme-inhibiting medications can interfere with endocrine and homeostatic mechanisms. There is also increasing concern about the association between some agents and deteriorating bone health.

The selection of an agent, therefore, should not be based only on whether a patient needs a drug for a particular clinical setting in which they have had an epileptic seizure. Instead, a therapy decision should incorporate the comorbidities such as weight gain and the risk of diabetes that the patient may face with particular agents.

This issue of Advanced Studies in Medicine is based on a roundtable symposium for neurologists, titled, "New-Onset Epilepsy: Emerging Trends and Strategies in Pharmacotherapy." The program was designed to examine the current treatment approaches to epilepsy including interactive discussion among the panel of experts. The objectives of the symposium were to determine when it is appropriate to initiate antiepileptic drug therapy, to discuss the impact of proposed epilepsy classification changes, and to discuss monotherapy trial data along with the consequences and comorbidities associated with treatment.

The epidemiology, etiology, and classification of epilepsy and seizures are discussed in my introductory presentation. Potential changes to current epilepsy and seizure classification are debated, as is the true incidence of epilepsy. Consideration is also given to special epileptic patient populations such as the elderly and pregnant women, who require additional input from specialists when deciding on a treatment strategy.

R. Eugene Ramsay, MD, discusses when it is appropriate to initiate antiepileptic therapy. The difficulty in defining what constitutes a first seizure is discussed, as well as the difference between seizure and epilepsy, the differential diagnoses that must be investigated, and the best tools for diagnosis. The long-term prognosis following a first seizure is also examined based on seizure cause, characteristics, and risk factors. The effect of early pharmacologic treatment on subsequent seizure rate is also considered.

Frank Gilliam, MD, presents the standards of evidence for pharmacological approaches to epilepsy with an examination of equivalency trial design and the relevance of various treatment groups within these trials. Interpreting clinical trial data for clinical use can be further complicated by the end points used, such as seizure control versus freedom from seizures. While monotherapy trials reduce some of the confounding factors, they can be more cumbersome requiring longer duration and greater expense. Nonetheless, trial results have failed to impact the standard of care in terms of first-line antiepileptic therapy used by emergency room and primary care physicians and more education is needed so that new-onset epilepsy patients are given better treatment options from the outset.

Dennis J. Dlugos, MD, continues with a discussion of pharmacological treatment considerations. Which currently available medications should be used at which target dose? Is therapeutic drug monitoring needed? And how should the first antiepileptic given to an individual patient be chosen? Emphasis is placed on whether higher doses of commonly used agents are proportionately beneficial as far as reduction in seizure frequency considering the increased risk of side effects.

*Professor of Neurology, Johns Hopkins University School of Medicine; Chairman of Neurology, Director, Epilepsy and EEG Program, Johns Hopkins Bayview Medical Center, Baltimore, Maryland.

 Assistant Professor of Neurology, Division of Cognitive Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Address correspondence to: Peter W. Kaplan, MBBS, FRCP, Department of Neurology, Johns Hopkins Hospital, B Building 1N, Room 122, 4940 Eastern Ave, Baltimore, MD 21224. E-mail:
pkaplan@jhmi.edu.





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.