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Topiramate and Temporal Lobe Epilepsy: an Open-Label Study

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Topiramate and Temporal Lobe Epilepsy: an Open-Label Study Original article Epileptic Disord 2012; 14 (2): 163-6 Topiramate and temporal lobe epilepsy: an open-label study Angelo Labate 1, Antonio Siniscalchi 2, Laura Mumoli 1, Umberto Aguglia 1, Aldo Quattrone 1, Antonio Gambardella 3 1 Institute of Neurology, University Magna Græcia, Catanzaro 2 Department of Neuroscience, Neurology Division, Annunziata Hospital, Cosenza 3 Institute of Neurological Sciences, National Research Council, Cosenza, Italy Received November 12, 2011; Accepted February 29, 2012 ABSTRACT – Purpose. To evaluate the efficacy and tolerability of topiramate (TPM) as monotherapy for patients with temporal lobe epileptic seizures based on an observational study. Methods. We evaluated 41 patients (20 female, mean age 54+18 years) with temporal lobe epilepsy (TLE) referred to the Epilepsy Unit, University of Catanzaro, Italy.Patients received TPM as monotherapy directly or after having taken other antiepileptic drugs. Seizure frequency changes and adverse events were recorded. Follow-up was conducted for a period of at least two years after treatment. Results. Patients received TPM, 50-600 mg/day, de novo (n=29) or initially as add-on therapy before the switch (n=12). In total, 28 of 41 patients achieved seizure freedom, whereas 10 showed a ≥50% reduction of seizure fre- quency. Two patients did not respond well and one patient discontinued TPM due to adverse effects. Conclusions. Our results confirm that TPM as either monotherapy or add-on therapy at doses of 50-600 mg/day effectively reduces seizure frequency in TLE. TPM is particular effective and very well tolerated in patients with mild TLE. Key words: topiramate, temporal lobe epilepsy, antiepileptic drugs Topiramate (TPM) is derived from tive therapy with standard AEDs D-fructose, initially used as an have demonstrated that TPM has antidiabetic drug. It is a novel a broad spectrum of actions, effec- antiepileptic drug (AED) having tive against partial-onset seizures been shown to have striking anti- (Giannakodimos et al. 2005; Jette epileptic action in animal models et al., 2008), primary generali- (Park et al., 2008). The use of sed tonic-clonic seizures (Bergey, these models indicated that TPM 2005), and seizures associated with exerts multiple actions such as an Lennox-Gastaut syndrome (Glauser inhibitory effect on sodium conduc- et al., 2000). The excellent results tance, increasing GABA-mediated of TPM as adjunctive therapy for chloride influx into neurons, and patients with refractory epilepsy, Correspondence: antagonism of amino-3-hydroxy-5- mainly with temporal lobe epilepsy Angelo Labate methyl-4-isoxazole propionic acid (TLE), suggested that this drug could Cattedra ed U.O. di Neurologia, AMPA/kainate glutamate receptor also be used as monotherapy. For Università degli Studi “Magna Græcia”, (Kaminski et al., 2004; Herrero TLE, the efficacy of TPM as mono- Campus Universitario Germaneto, Viale Europa, 88100 Catanzaro, Italy et al., 2002; Jette et al., 2008). Several therapy, as for many other AEDs, has <[email protected]> doi:10.1684/epd.2012.0497 clinical trials of TPM as adjunc- only been evaluated in adults with Epileptic Disord, Vol. 14, No. 2, June 2012 163 A. Labate, et al. chronic, refractory partial-onset seizures (Sachdeo were labelled as unilateral if confined to one temporal et al., 1997), despite some forms of epilepsy having a side at least 95% of the time. All patients had a conven- mild course. Recent studies described clinical features tional MRI (1.5 Tesla) examination, based on a protocol and outcome of TLE patients who had a benign form of routinely used for patients with epilepsy (Labate et al., TLE (bTLE) (Aguglia et al., 1998; Gambardella et al., 2003; 2006), including T2-weighted images, and a coronal Labate et al., 2011). Furthermore, MRI evidence of hip- 3D sequence with contiguous slices, with and with- pocampal sclerosis (HS) in about 40% of these patients out administration of gadolinium. Exclusion criteria with bTLE has pointed out that the presence of HS itself were: extratemporal epilepsies, generalised epilep- does not necessarily indicate intractable epilepsy with sies, status epilepticus, epilepsia partialis continua, a worse outcome as previously thought (Labate et al., non-epileptic seizures, clinically significant laboratory 2006; Labate et al., 2008; Labate et al., 2011). abnormalities, nephrolithiasis, mental retardation, To evaluate the efficacy of TPM in a population of TLE poor compliance, pregnancy, alcohol or drug abuse patients with mild and refractory partial epilepsy, we within the past years, hypersensitivity to carbonic conducted an observational open-label study in adults anhydrase inhibitors or sulfonamides, and suicide and children taking TPM as monotherapy or as a sec- attempt or psychiatric disorder requiring therapy. Each ond AED choice due to inefficacy of the first AED. patient received a starting dose of 12.5 mg TPM nightly for a week and a following increment to at least 50 mg/day over four weeks, while withdrawl of any anti- Patients and methods convulsant being used previously without efficacy was initiated. This open-label study was conducted at an epilepsy Patients were clinically observed every three months outpatient clinic at the University of Catanzaro from during a follow-up of more than two years. Firstly, June 2009. Patients were eligible for the study if they the efficacy was assessed by measuring changes in were at least three years of age. The study group con- seizure frequency and secondly, side effects and tole- sisted of 41 consecutive patients (20 females; mean rability were observed. We classified patients after age: 54+18 years) referred to our clinic and recruited treatment into four categories: seizure freedom, ≥50% prospectively. The study was approved by the Uni- seizure reduction; <50% seizure reduction, and those versity Hospital Ethics Committee and all subjects that withdrew from the trial. Diagnosis, treatment deci- and their guardians, in the case of children, gave sion and grading the efficacy were made by a single informed consent to participate. For all patients, the trained neurologist with special expertise in epilepsy diagnosis of epilepsy was based on the International (AL). Classification of Epilepsies (Commission, 1989). The Categorical variables were reported as counts and following features were noted: sex, age, history of percentage. Frequency distributions among patient migraine, seizure type, AEDs used prior to TPM, age groups were compared using the ␹2 test and Monte at epilepsy onset, seizure frequency, abnormal phy- Carlo or Fisher exact test, as appropriate, when the sical and neurological examination, family history of expected frequencies were low. The unpaired t-test epilepsy or febrile convulsions (FC), and laboratory was used to evaluate differences in mean of conti- and neuroimaging findings. Seizure types were identi- nuous variables among groups. Statistical analysis was fied according to the classification of epileptic seizures performed using the Statistical Package for Social and syndromes by the International League Against Science software (SPSS, version 17.0, Chicago, IL) for Epilepsy (Commission, 1989). The diagnosis of TLE was Windows. made on the basis of a constellation of clinical, EEG, and MRI criteria which are considered to be reliable inter- ictal indicators of TLE (Commission, 1989). The diagno- Results sis of TLE was mainly based on typical temporal auras or interictal EEG discharges, maximum over the tempo- Clinical characteristics of patients are summarised in ral lobes. Any suggestion of seizure onset outside the table 1. In detail, 29 (70%) of 41 subjects had benign mesial temporal structures by semiology or EEG find- TLE with very mild epilepsy (bTLE), i.e. seizure-free ings was an exclusion criterion. All patients underwent patients or patients with either occasional auras or not several interictal EEGs including routine EEGs while more than two disabling (complex partial or secondary awake and asleep. The interictal EEGs were recorded generalised) seizures per year for at least two follow- according to the 10-20 international system with sup- ing years. The remaining 12 subjects had symptomatic plementary T1 and T2 electrodes (Gambardella et al., epilepsy (sTLE); four of these patients had HS, four 1998). The EEG abnormalities (spikes, spike waves, and patients had vascular lesions, two patients had a brain runs of sharp theta/delta waves of temporal intermit- tumour, and three had post-traumatic gliosis. The diag- tent rhythmic delta activity over one temporal region) nosis of both bTLE and sTLE was made before starting 164 Epileptic Disord, Vol. 14, No. 2, June 2012 Topiramate and TLE Table 1. Features in patients with bTLE or sTLE. 40 35 Clinical Features bTLE sTLE (n=29) (n=12) 30 25 ± ± ± Age (Mean SD) 57 17 52 19 20 bTLE ± ± ± 15 Age at onset (Mean SD) 48 18,7 34,7 21,3 N° Patients 10 sTLE Sex (n, %) bTLE 5 sTLE Male 13 8 sTLE bTLE Female 16 4 0 Seizure freedom ≥50-99% Seizure <50% Seizure Drop out frequency reduction frequency reduction Familial history of epilepsy (n,%) 5 (17) 3 (25) Response to TPM therapy Febrile convulsions (n,%) 1 (3,4) 1 (8,3) Figure 1. Overall response to TPM treatment in patients with Mean dose of TPM (mg/day) 197±13 379±13 bTLE and sTLE. EEG (n, %) Normal 8 0 between sex (p=0.240), age at onset (p=0.097), and Left spikes or/and sharp waves 7 7 family history of epilepsy (p=0.240). Right spikes or/and 11 2 No changes on interictal EEGs were observed during sharp waves the follow-up. Bilateral spikes or/and 33 sharp waves Discussion Previous drugs (n, %) To our knowledge, this is the first open-label study that Carbamazepine 6 reports on the efficacy and safety of TPM as mono- Clobazam 2 therapy for the treatment of temporal lobe epileptic Lamotrigine 2 patients regardless of their seizure frequency. Fenobarbital 2 TPM has been extensively reported to be effective as None 29 add-on therapy for refractory partial epilepsy in sev- bTLE benign temporal lobe epilepsy; sTLE: symptomatic temporal eral placebo-controlled studies (Sachdeo et al., 1997; lobe epilepsy; TPM: topiramate.
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