Focal Onset Seizures: New Treatment Options in The Clinical Practice

Abstract

This symposium took place during the 2023 Congress of the European Academy of Neurology (EAN). Mar Carreño, Director, Epilepsy Unit, Hospital Clínic and Instituto Clavel, Barcelona, Spain, presented the definition of drug-resistant epilepsy (DRE), and stressed that uncontrolled epilepsy does not necessarily indicate DRE. Before a diagnosis of DRE is made in a patient not responding to medication, questions should be asked regarding the initial epilepsy diagnosis. Carreño discussed paroxysmal events that may mimic epilepsy, and presented three cases of misdiagnosed DRE that were subsequently correctly identified as cardiac syncope, a psychogenic event, and use of inappropriate medication in a patient with generalised epilepsy. The second part of Carreño’s presentation focused on patients with confirmed DRE. They outlined the complications of DRE, including sudden unexpected death in epilepsy (SUDEP), which should be discussed with the patient. Carreño finished their lecture with a discussion of comorbid conditions, including neuropsychiatric comorbidities, which affect one in three patients with epilepsy. Bernhard J. Steinhoff, Medical Director, Kork Epilepsy Center, Kehl, Germany, then discussed the clinical approach to patients with DRE, including treatment options, the range of anti-seizure medications (ASM), and the reasons for failure of first-line treatment, noting that the probability of achieving seizure freedom decreases with each failed ASM. Steinhoff explored the options of substitution monotherapy or combination therapy after failure of the first ASM, before describing cenobamate (CNB) add-on therapy. A randomised, placebo-controlled, dose-response trial showed that adjunctive CNB reduced focal (partial)-onset seizure frequency in a dose-related fashion. Several papers have been published providing real-world evidence to show that adjunctive CNB therapy is associated with improved seizure outcomes, and that the number of concomitant ASMs could be reduced. The symposium concluded with a question and answer session.