Earlier Is Not Always Better: Outcomes When Epilepsy Occurs in Early Life Versus Adolescence

Immediate Outcomes in Early Life Epilepsy: A Contemporary Account Berg AT, Wusthoff C, Shellhaas RA, et al. Epilepsy Behav. 2019;97:44-50. doi:10.1016/j.yebeh.2019.05.011. Epub 2019 Jun 7. PMID: 31181428 Rationale: Early-life epilepsies include some of the most challenging forms of epilepsy to manage. Given recent diagnostic and therapeutic advances, a contemporary assessment of the immediate short-term outcomes can provide a valuable framework for identifying priorities and benchmarks for evaluating quality improvement efforts. Methods: Children with newly diagnosed epilepsy and onset <3 years were prospectively recruited through 17 US hospitals, from 2012 to 2015 and followed for 1 year after diagnosis. Short-term outcome included mortality, drug resistance, evolution of nonsyndromic epilepsy to infantile spasms (IS) and from IS to other epilepsies, and developmental decline. Multivariable analyses assessed the risk of each outcome. Results: Seven hundred seventy-five children were recruited, including 408 (53%) boys. Median age at onset was 7.5 months (interquartile range [IQR]: 4.2-16.5), and 509 (66%) had onset in the first year of life. Of 22 deaths that occurred within 1 year of epilepsy diagnosis, 21 were children with epilepsy onset in infancy (<12 months). Of 680 children followed ≥6 months, 239 (35%) developed drug-resistant seizures; 34/227 (15%) infants with nonsyndromic epilepsy developed IS, and 48/210 (23%) initially presenting with IS developed additional seizure types. One hundred (23%) of 435 with initially typical development or only mild/equivocal delays at seizure onset, had clear developmental impairment within 1 year after initial diagnosis. Each outcome had a different set of predictors; however, younger age and impaired development at seizure onset were broadly indicative of poorer outcomes. Type of epilepsy and early identification of underlying cause were not reliable predictors of these outcomes. Conclusion: Early-life epilepsies carry a high risk of poor outcome which is evident shortly after epilepsy diagnosis. Onset in infancy and developmental delay is associated with an especially high risk, regardless of epilepsy type. The likelihood of poor outcomes is worrisome regardless of specific clinical profiles. : Pharmacological Outcomes in Teenagers With Newly Diagnosed Epilepsy: A 30-Year Cohort Study Alsfouk BA, Alsfouk AA, Chen Z, Kwan P, Brodie MJ. Epilepsia. 2019;60(6):1083-1090. doi:10.1111/epi.15664. Epub 2019 May 21. PMID: 31111485 Objective: To evaluate the long-term pharmacological outcomes in teenagers with different epilepsies. Method: This study included teenagers aged 13 to 19 years at treatment initiation who were newly treated with antiepileptic drugs (AEDs) at the epilepsy unit of the Western Infirmary in Glasgow, Scotland, between 1 September 1982 and 30 September 2012. Patients were prospectively followed until April 30, 2016, or death, with at least a 2-year follow-up. Results: A total of 332 adolescent patients (53% female; median age 16 years; 54% with generalized epilepsy) were included. At the end of the study, 221 (67%) patients were seizure-free. A higher seizure-free rate was observed in those with generalized compared to focal epilepsy (72% vs 60%, P =.01). During the study, 108 patients had relapses after periods of being seizure-free, most commonly due to poor adherence to AEDs (49%, n = 53/108). Antiepileptic drug withdrawal was associated with a high risk of seizure recurrence (70%, n = 26/37), but 56% (n = 61/108) of relapsed patients became seizure-free again by the end of the study, with only 9% (n = 31/332) meeting the International League Against Epilepsy definition of pharmacoresistance during follow-up. Of the 221 seizure-free patients, 83% achieved this on monotherapy. There was no significant difference in efficacy rate between new and standard AED monotherapy (74% vs 77%, P =.66). The overall poor tolerability rate of AEDs was 21% (n = 69/332). Among the different new and standard AEDs used as initial monotherapy, lamotrigine was associated with the lowest rate of adverse effects (12%, n = 15/124), while topiramate was associated with the highest rate (56%, n = 5/9). Significance: Teenagers with epilepsy showed good seizure control, particularly those with generalized epilepsy. However, relapse was common and there was high risk of seizure recurrence after treatment withdrawal. Most patients were controlled on monotherapy. As the efficacy of AEDs was comparable, tolerability can be a primary consideration for AED selection in this population.