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Dr. Andrew Rynne
MD
Dr. Andrew Rynne

Family Physician

Exp 50 years

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Thank you for your very complete answer to my previous

Answered by
Dr.
Dr. Dariush Saghafi

Neurologist

Practicing since :1988

Answered : 2429 Questions

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Posted on Tue, 26 Feb 2019 in General Health
Question: Thank you for your very complete answer to my previous question. I have one more. Information provided with the Vimpat says that there were insufficient numbers of elderly patients enrolled in partial-onset seizure trials (n=18) to adequately assess the effectiveness of VIMPAT to the population. Do you have any more data on the effectiveness to elderly patients?. Also mention was made by the doctor we consulted about the fact that Vimpat was a "cleaner" drug than Keppra. I am not sure what "cleaner" means in this context. Thanks for your help!
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Answered by Dr. Dariush Saghafi 17 hours later
Brief Answer:
Many Thanks for your Complimentary Return Question

Detailed Answer:
I wish to thank you for sending me a PERSONAL followup question and for recognizing the value of the information I provided in the last response I sent. I shall be happy to respond to this question as well and hope it gives you a bit more of a base to stand on as you make your decision between one medication and another to treat your condition of seizure disorder.

The phrase, "cleaner" used in medical lingo usually refers to a drug's side effect profile being less aggressive, "softer" is a term I like to use, or more BENIGN in terms of drug to drug reactions in a certain population of patients. In this case, I'm not absolutely clear on which of those variable interpretations of the word "cleaner" this colleague may be referring nor have you cited (likely because he didn't either) the doctor's sources that support the notion of this CLEANER profile in the >65 population, however, I can tell you that at perhaps the least likely level of confidence regarding Keppra's superiority over Vimpat (i.e. personal or institutional preferences) in our Academic Center (which is recognized as a National Center of Excellence in Epilepsy), the epileptologists, as far as I have ever seen in patients I treat use KEPPRA (levetiracetam) as the first line drug to treat partial seizure disorders in virtually all age groups (including the elderly) due to its remarkably good compatibility with many other medications that people (especially elderly take). Also, it just appears to work more consistently and more quickly to control seizures compared to other medications used to treat partial seizures (and there are a number). Vimpat by comparison is never used as a 1st line choice that I've ever seen in our institution (and I do treat many patients with seizures according to style and recommendations of our epileptologists). Efficacy using Vimpat compared to Keppra is probably similar, however, duration in titration to find adequate control levels with Keppra seems to be one of the fastest compared to all others with similar capacity to treat partial seizures. I can tell you that in my patients, titration of Vimpat is a more drawn out process to gain control of seizures compared to Keppra and so I prefer Keppra as a starter.

From a more OBJECTIVE side of arguing in favor of Keppra I can tell you that one of the most utilized and trusted resources that many doctors regard as highly valid as a fund of knowledge upon which to make clinical decisions is called UpToDate.

There is a professional article entitled Treatment of Seizures and Epilepsy in Older Adults which was last updated by the authors in 2017. Here are both Vimpat (lacosamide) and Keppra (levetiracetam) in a table they present of drugs used to treat seizures in "elderly patients" which lists some of the more common NEUROLOGICAL side effects:

Lacosamide      Nausea, vomiting, fatigue, Ataxia, dizziness, headache, diplopia

Levetiracetam      Fatigue, somnolence, dizziness, agitation, anxiety,
irritability, depression

In a 2nd table there is a listing of the more RARE BUT SERIOUS SIDE EFFECTS of these 2 drugs:

Lacosamide      Prolonged PR interval, atrioventricular block, multiorgan
hypersensitivity, neutropenia

Levetiracetam      Stevens-Johnson Syndrome, anaphylaxis and angioedema,
pancytopenia, psychosis

Neither of these drugs is the PERFECT one by any means in terms of potential hazards to patients but in my opinion as well as the opinions of our Epilepsy faculty it is still considered superior since the incidence of these side effects is very low (in both drugs) but the speed to controlling patients and the ease with combining other drugs is much more in favor of Keppra than Vimpat.

There is also another very important point to mention about side effects of VIMPAT not mentioned in this UPTODATE article which comes from another article entitled Tolerability of lacosamide or zonisamide in elderly patients with seizures published in July 2017 which demonstrated that 27% of studied patients discontinued their drug due to at least one of the following side effects:

Dizziness/gait instability, Fatigue, Cognitive or behavioral difficulties, memory loss/cognitive slowing, depression/irritability, anxiety, paresthesias, diplopia

In a study that was conducted looking at the safety profile for Keppra (levetiracetam) entitled Levetiracetam: The Anti-Convulsant of Choice for Elderly Patients With Dementia published in 2008, this single piece of information stands out in my mind as making it superior to virtually EVERY OTHER MEDICATION used to treat partial seizures in the elderly:

KEPPRA (unlike any other medication used to treat partial seizures in the elderly) was shown to have NO COGNITIVE ADVERSE EFFECTS on elderly patients with BOTH seizures and DEMENTIA. Therefore, if this medication's side effect profile on mentation during use in patients with DEMENTIA was measured as so NEUTRAL over the course of the study then, imagine how minimal that particular side effect would be expected to be in patients WITHOUT dementia (such as yourself)?

This is a major point that I point to all the time with my patients that I start on Keppra (especially my elderly ones) who are very concerned about how their memories and other cognitive capabilities will be affected. VIMPAT can make no such claim in terms of being that neutral with respect to cognitive affectation.

I could continue demonstration even other articles and other reasons (some more concrete, others more on the basis of style and preference), however, the bottom line is that I do not find the side effect profile of VIMPAT to be necessarily "cleaner" compared to Keppra and in fact, would suggest on the basis of some of the above information that it is known to cause more potential negative impact in the elderly population under certain circumstances.

We know that the drug to drug interactions of VIMPAT are definitely more numerous and adverse in many cases to that of KEPPRA and we also know from studies that VIMPAT (as most drugs) has an increasing incidence of side effects or intensity of side effects as dosages are increased whereas there are studies of KEPPRA showing NO INCREASE in the number or intensity of adverse events with changes of dosing for the purpose of titrating the medication to efficacy.

Therefore, in conclusion, I believe this information still supports the use of KEPPRA in the elderly population in order to control seizures over many other AED's including VIMPAT.

If I've provided useful and helpful information to your question could you once again do me the favor of CLOSING THE QUERY along with some POSITIVE words of feedback on the site along with a 5 STAR rating? I would be personally interested in any rationale or literature your physician chooses to share with you that suggests VIMPAT to be superior to KEPPRA in the elderly population since I may take this under consideration for my own patients in the future if from appropriately supported sources.

Do not forget to contact me in the future at: www.bit.ly/drdariushsaghafi for additional questions, comments, or concerns having to do with this topic or others.

This query has utilized a total of 180 minutes of professional time in research, review, and synthesis for the purpose of formulating a return response.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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