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


A New Era of Therapeutic Strategies for Epilepsy Patients


GOAL
To provide physicians with current information on new advances in the management and treatment of epilepsy.

TARGET AUDIENCE
This activity is designed for neurologists, particularly those who treat patients with epilepsy.

LEARNING OBJECTIVES
After reading this issue, the participant should be able to:

  • Identify the imaging method of choice for evaluating potential epilepsy surgery candidates.
  • Describe the risk factors for postsurgical carbamazepine toxicity in epilepsy surgery patients.
  • Identify the common reasons for antiepilepsy drug (AED) failure.

ACCREDITATION STATEMENT
This activity has been planned and produced in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education. The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians. The Johns Hopkins School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this continuing medical education activity for a maximum of 2 hours in Category 1 credit toward the American Medical Association Physician's Recognition Award. Each physician should claim only those hours of credit that are actually spent on the educational activity. Credits are available until the expiration date of October 30, 2003.

This continuing education activity was produced under the supervision of Ronald P. Lesser, MD, Professor of Neurology, Johns Hopkins University School of Medicine.

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

Publisher's Note and Disclaimer: The opinions expressed in this issue are those of the authors, presenters, and/or panelists and are not attributable to the publisher, editor, advisory board of Advanced Studies in Medicine, or The Johns Hopkins University School of Medicine or its Office of Continuing Medical Education. Clinical judgment must guide each professional in weighing the benefits of treatment against the risk of toxicity. Dosages, indications, and methods of use for products referred to in this issue are not necessarily the same as indicated in the package insert for the product and may reflect the clinical experience of the authors, presenters, and/or panelists or may be derived from the professional literature or other clinical sources. Consult complete prescribing information before administering.

Advanced Studies in Medicine (ISSN-1530-3004) is published by Galen Publishing, LLC, an HMG Company. P.O. Box 340, Somerville, NJ 08876. (908) 253-9001. Web site: www.galenpublishing.com. Copyright ©2001 by Galen Publishing, LLC. 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. Bulk postage paid at Somerville, NJ Post Office and at additional mailing offices. Advanced Studies in Medicine is a registered trademark of The Healthcare Media Group, LLC. Printed on acid-free paper. BPA Membership applied for December 2000.

The contents of this issue of Advanced Studies in Medicine include highlights from the 53rd annual meeting of the american academy of neurology held on May 5-11, 2001, in Philadelphia, Pennsylvania.

FACULTY ADVISORS

    Ronald P. Lesser, MD
    Professor of Neurology
    Johns Hopkins University School of Medicine
    Baltimore, Maryland
    • Dr. Lesser reports serving on the speakers' bureau for, or having lectures supported by, Abbott Laboratories, Novartis, Ortho-McNeil, Wallace Laboratories, Warner-Lambert/Parke-Davis, and Wyeth; serving as a consultant for Medtronic, Inc.; and receiving funding and sales royalties from Biologic Systems, Inc.

PARTICIPATING FACULTY

    Robert S. Fisher, MD, PhD
    Professor of Neurology and Neurological Sciences
    Director, Stanford Comprehensive Epilepsy Center
    Department of Neurology
    Stanford University Medical Center
    Stanford, California
    • Dr. Fisher reports serving as a speaker for and a consultant to Pfizer, Glaxo, and UCB Pharma; serving as a consultant to and receiving research support from Medtronic; and serving as a consultant to and receiving royalties from Nicolet.

    Mark Mintz, MD
    Chief Medical Director
    Bancroft NeuroHealth
    Haddonfield, New Jersey
    Adjunct Associate Professor of Pediatrics and Neurology
    University of Pennsylvania School of Medicine
    The Children's Hospital of Philadelphia
    Philadelphia, Pennsylvania
    • Dr. Mintz reports receiving lecture and/or research support from Shire, Sigma Tau, UCB Pharma, Cephalon, and Celltech; serving on the advisory board and/or speakers' bureau for UCB Pharma, Ortho-McNeil, Glaxo SmithKline, and Parke-Davis.

    Martha J. Morrell, MD
    Director, Columbia Comprehensive Epilepsy Center
    The Neurological Institute of New York
    New York Presbyterian Hospital
    New York, New York
    • Dr. Morrell reports receiving grant/research support from Glaxo Wellcome, Cyberonics, Novartis, Parke-Davis, and Abbott; and serving as a consultant to Glaxo Wellcome, Elan, Shire, Novartis, and Ortho-McNeil.

    Dean K. Naritoku, MD
    Associate Professor of Neurology and Pharmacology
    Director, Center for Epilepsy
    Department of Neurology
    Southern Illinois University
    Springfield, Illinois
    • Dr. Naritoku reports receiving research support from Pfizer, Abbott, Cyberonics, Glaxo Wellcome, Ortho-McNeil, and Park-Davis; serving on the speakers' bureaus for Abbott, Elan, Ortho-McNeil, and UCB Pharma; and serving as a consultant to Abbott, Elan, and Ortho-McNeil.

    Steven C. Schachter, MD
    Associate Professor of Neurology
    Harvard Medical School
    Boston, Massachusetts
    • Dr. Schachter reports receiving lecture support from Novartis, Glaxo SmithKline, and Shire.

Advanced Studies in Medicine provides disclosure information from contributing authors, participating faculty, and presenters only. 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.

A New Era of Therapeutic Strategies for Epilepsy Patients
Ronald P. Lesser, MD1

The treatment of epilepsy is beginning a new era. We have seen advances in neuroimaging, surgical techniques, seizure localization procedures, and, within the last decade, 8 new drugs. Dr. Steven C. Schachter, in his presentation during the educational program at the 53rd Annual Meeting of the American Academy of Neurology (AAN) May 5-11, 2001, in Philadelphia, Pennsylvania, presented a very relevant review to clinical neurologists on the 5 most recent antiepileptic drugs (AEDs) to be approved by the Food and Drug Administration. He discussed their proposed mechanisms of action, pharmacokinetics, drug-drug interactions, and side effects. He also reviewed the objectives of antiepileptic therapy and why those objectives are not met in some patients. Dr. Schachter also provided a useful discussion of when to initiate therapy (including new paradigms on this issue) and when to switch therapies.

In related presentations, Dr. Mark Mintz discussed his results of a study evaluating a possible cause of some topiramate-associated side effects-metabolic acidosis. He found that bicarbonate supplementation could reduce side effects in some patients. Dr. Dean K. Naritoku evaluated intravenous valproic acid (IV VPA) in different types of status epilepticus patients (simple partial, complex partial, overt convulsive, and subtle convulsive). He found IV VPA to be effective therapy in many patients, including those who had not responded to primary drugs.

The poster presentations followed suit by looking at the uses of the latest AEDs in natural clinical settings and at ways that their administration can be optimized. Dr. Alan Guberman and colleagues showed that a slower initial titration schedule, and lower final dose, can be effective in treating partial seizures, causing fewer side effects and therefore fewer interruptions or discontinuations. Dr. David Mandelbaum et al described that 2 new drugs (levetiracetam and zonisamide) each could reduce seizures by 90% to 100% in about one third of children with intractable epilepsy. Similarly, Dr. Michael Privitera et al compared 2 doses of topiramate with carbamazepine and valproic acid in a clinical setting. Each could be effective in controlling seizures, with a slightly higher percentage of seizure-free patients in the low-dose topiramate group. Dr. David Loring et al compared the cognitive effects of topiramate with valproate and placebo as add-on therapy. They found surprising similarities in the spectrum of side effects among the 3 groups. Dr. Alexander Aranda et al measured the serum levels of lamotrigine when co-administered with other commonly used AEDs and found that levels above 20 mg/mL were more likely to be associated with toxicity.

The educational program at the AAN meeting was the venue for other practical information for clinicians. Dr. Robert S. Fisher offers an overview of surgery for intractable epilepsy patients and the methods used to localize seizure foci. He reviews the criteria for surgery, which are important for both neurologists and our primary care colleagues, especially since, as Dr. Fisher clearly shows, temporal lobectomies are grossly underutilized, so many candidates are not receiving optimal treatment.

Finally, Dr. Martha J. Morrell eloquently discusses the psychological and physiological consequences of epilepsy. Clearly the consequences are interdependent and are a major source of morbidity for epilepsy patients. These are the sequelae that the patients deal with day after day. The actual trauma of a seizure exists in pockets of time (seconds or minutes); the effect of epilepsy on the patient's life is almost constant. Dr. Morrell reviews the not-so-rare "sudden unexplained death in epilepsy" phenomenon and how and when to discuss it with patients. She also provides a useful review of the different types of reproductive dysfunction that both male and female (although primarily female) epilepsy patients experience. These issues have significant effects on quality of life-lower marriage rates, higher infertility, lower employment rates, and fear, to name a few.

We all should welcome the advances made in therapeutic strategies for epilepsy patients. Greater understanding of the ways in which these therapies will interact will help us to offer optimal, appropriately tailored therapies to our patients.

1 Professor of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland.





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.