Beyond Seizure Control: A Fresh Outlook on Comprehensive Treatment for Drug-Resistant Epilepsy

You’re dedicated to helping your patients achieve seizure freedom, yet it’s wearing you down. It could just be a matter of perspective.

If not being able to attain complete seizure freedom for your patients weighs heavily on you, it’s understandable. Many neurologists who treat drug-resistant epilepsy (DRE) feel this way, as eliminating seizures is extremely challenging and often marred with complications that cannot be controlled.

Navigating the complexities of DRE treatment may feel like aiming at a moving target, so trying to find all the answers can certainly be frustrating. As an epilepsy specialist, you already face an onslaught of daily challenges, including1,2:

·      Diversity in epilepsy/seizure types and responses to treatment

·      Syndromic treatment resistance

·      Pharmacokinetic variability

·      Adverse effects

·      Patient compliance issues

Alongside these challenges, concern that adjusting or adding to your patient’s antiseizure medication (ASM) treatment regimen may increase or worsen side effects casts a formidable shadow. It’s no secret that some ASMs can worsen a patient’s mood, diminish their cognitive function, or impair their coordination.3 Combining multiple ASMs may intensify these unwanted outcomes, creating internal conflict between your desire to avoid polypharmacy and your goal of reducing seizure frequency.

These conflicting objectives carry a palpable weight. Seizure frequency is an obvious measure of DRE, so it makes sense that you’ve been prioritizing seizure reduction in treatment plans.3 However, the situation becomes more complicated when you consider the true nature of epilepsy as a disorder. Not only is achieving seizure control rare, but there are often ongoing, coinciding symptoms that can be deeply burdensome for patients.2 For example, cognitive impairment, behavioral worsening, and psychiatric co-morbidities are all known DRE complications.3 Despite their significant impact on patients’ daily lives, relationships, and even educational and employment opportunities, such co-morbidities are often overlooked or left untreated so that seizure reduction efforts can be the main focus.

In the world of DRE, it’s crucial to recognize that seizures aren’t the sole determinants of a patient’s quality of life (QOL). Co-existing conditions, as mentioned above, actually prove more bothersome in many cases, enveloping patients’ daily lives in a shrowd of darkness.

Take, for instance, anxiety. Imagine the daily battle: unpredictable seizures, constant worry, and the fear that even minor incidents could escalate into life-altering events. A common companion to epilepsy, anxiety can weave its way into every aspect of a patient’s life. With its relentless grip, some patients may feel greatly hindered in their ability to engage with the world, affecting relationships, daily activities, and even the pursuit of personal aspirations.

There are six common co-morbidities that often affect patients with DRE, including depression and anxiety.

Living with DRE is conflicting for patients, as they attempt to balance seizure management with QOL preservation. While they certainly want relief from co-morbidities to improve their overall well-being, they also dread being burdened by multiple medications. Side effects, the fatigue that comes from managing a complex treatment regimen, and financial strain all add to patients’ competing priorities. Unsurprisingly, they often find themselves caught in a contradictory loop: yearning for an improved QOL, while grappling with the fear that the very medications meant to help might exacerbate their struggles.

Third-generation ASMs that aim to improve symptoms beyond seizure control are entering the spotlight. These novel therapies aren’t just another addition to your arsenal; they show promise as a paradigm shift focusing on what your patients truly desire—improved QOL. Let’s say you have a patient who is juggling both epilepsy and anxiety. They’ve been taking traditional ASMs, which helps them control their seizures but worsens their anxiety. This creates a Catch-22 situation that they have to deal with daily. In contrast, the emerging third-generation ASMs offer the dual benefit of managing seizures effectively while also having a more favorable mental health profile, even improving anxiety symptoms for some. Opting for third-generation ASMs in your practice, you’d do more than update treatment protocols; you’d be part of a movement to renew a sense of normalcy and uplift the well-being of your patients living with DRE.

One treatment approach that’s attracting a lot of DRE patients’ attention, due to its potential to manage seizures and co-morbidities, is centered around CBD.1,4 In 2018, the FDA approved a plant-derived, highly purified CBD, Epidiolex for the treatment of seizures associated with Lennox-Gastaut syndrome, Dravet syndrome, and tuberous sclerosis complex.5,6 Beyond seizure reduction, CBD has been reported to enhance overall well-being by improving cognition, behavior, mood, and various aspects of health-related QOL.4 As you can see, exploring CBD treatments like Epidiolex isn’t just about managing seizures—it introduces a fresh perspective on tackling co-morbidities and improving the overall QOL for patients struggling with DRE.  

Taking a comprehensive and holistic approach to epilepsy management that prioritizes the QOL of your patients could allow them to live a more fulfilled life. The emergence of third-generation ASMs, like CBD, offers a promising avenue for comprehensive DRE management.

To learn more about CBD’s mechanism of action, continue following this article series.

References:

1.         Fattorusso A, Matricardi S, Mencaroni E, et al. The Pharmacoresistant Epilepsy: An Overview on Existant and New Emerging Therapies. Front Neurol. 2021;12:674483. doi:10.3389/fneur.2021.674483

2.         Ghosh S, Sinha JK, Khan T, et al. Pharmacological and Therapeutic Approaches in the Treatment of Epilepsy. Biomedicines. 2021;9(5):470. doi:10.3390/biomedicines9050470

3.         Guery D, Rheims S. Clinical Management of Drug Resistant Epilepsy: A Review on Current Strategies. Neuropsychiatr Dis Treat. 2021;17:2229-2242. doi:10.2147/NDT.S256699

4.         Elliott J, DeJean D, Clifford T, et al. Cannabis-based products for pediatric epilepsy: An updated systematic review. Seizure. 2020;75:18-22. doi:10.1016/j.seizure.2019.12.006

5.         Lattanzi S, Trinka E, Striano P, et al. Highly Purified Cannabidiol for Epilepsy Treatment: A Systematic Review of Epileptic Conditions Beyond Dravet Syndrome and Lennox-Gastaut Syndrome. CNS Drugs. 2021;35(3):265-281. doi:10.1007/s40263-021-00807-y

6. EPIDIOLEX (cannabidiol) oral solution [package insert]. Palo Alto, CA: Jazz Pharmaceuticals,    Inc. 2023.