Infantile Spasm, West Syndrome
Conditions
Keywords
Infantile Spasm, Vigabatrin, Prednisolone, Treatment, West Syndrome
Brief summary
Infantile spasms (IS) are seizures associated with a severe infantile epileptic encephalopathy. Both cessation of spasms and electrographic response are necessary for the best neurodevelopmental outcomes. Adrenocorticotrophic hormone (ACTH), or prednisolone, or vigabatrin are considered the first-line treatment individually. However, ACTH expense and availability are the barriers in developing countries including Thailand. Vigabatrin, therefore, is the first recommended by Epilepsy Society of Thailand due to ACTH unavailability. Recently, combined steroid treatments (either ACTH or high dose prednisolone) with vigabatrin are superior in cessation of spasms compared to steroid treatment alone. Thus, this study is aimed to compare the efficacy of vigabatrin with high dose prednisolone combination therapy and vigabatrin alone.
Detailed description
Infantile spasms are recognized as epileptic encephalopathy which include the hypsarrhythmia or variants electroencephalographic (EEG) features and psychomotor regression. Various underlying conditions are associated with the infantile spasm included cerebral malformation, hypoxic ischemic encephalopathy, genetic disorders (Down syndrome), tuberous sclerosis complex (TSC), etc. Although vigabatrin has the evidence to use as the first line treatment for infantile spasm related with TSC. Adrenocorticotrophic hormone (ACTH), or high dose prednisolone, or vigabatrin are the first line treatment of IS in non-TSC. The effectiveness of ACTH versus high dose prednisolone question have not yet definitely answered. Furthermore, ACTH expense and availability are the barriers in developing countries including Thailand. Vigabatrin, therefore, is the first option of therapy recommended by Epilepsy Society of Thailand due to ACTH unavailability. Recently, combined steroid treatments (either ACTH or high dose prednisolone) with vigabatrin are superior in cessation of spasms compared to steroid treatment alone. Questions about the clinical cessation of IS and electrographic remission by combination treatment with vigabatrin and high dose prednisolone compare to vigabatrin alone have not fully elucidated. Thus, this study is aimed to compare the efficacy of vigabatrin with high dose prednisolone combination therapy and vigabatrin alone.
Interventions
DRUGCombination therapy with vigabatrin and prednisolone
High dose prednisolone (40 - 60 mg/day) for 1 month combined with vigabatrin treatment (50-150 mg/kg/day) twice daily for 4 months
DRUGVigabatrin Tablets
Vigabatrin (50-150 mg/kg/day) twice daily for 4 months
Sponsors
Kullasate Sakpichaisakul
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
DOUBLE (Investigator, Outcomes Assessor)
Masking description
Each patient will visit the clinic at Day 8, 14, 43, and 3 months by outcome assessor who is blinded for treatment to determine seizure frequency and adverse events. Those patients will be seen and under taking care of primary neurologists and pharmacists who are not blinded to treatment at the same visit as a standard clinical practice and check with compliance and adjust vigabatrin or prednisolone following each treatment allocated (if needed). Family or caregivers will not be blinded to treatment. EEG will be scored using BASED scores at Day 0 (before treatment), 14, and 43 to assess the resolution of hypsarrhythmia.
Intervention model description
A pragmatic parallel group randomised trial comparing vigabatrin with high dose prednisolone to vigabatrin treatment alone in the treatment of infantile spasm.
Eligibility
Sex/Gender
ALL
Age
2 Months to 14 Months
Healthy volunteers
No
Inclusion criteria
* Age at 2-14 months at date of enrollment * Clinical diagnosis of infantile spasm assessed by pediatric neurologist and hypsarrhythmic pattern or variants interpreted by pediatric epileptologist * Thai nationality
Exclusion criteria
* Previous treatment (within the last 28 days) with vigabatrin or corticosteroid * Previous diagnosis of epileptic encephalopathy e.g. early infantile epileptic encephalopathy and early myoclonic epileptic encephalopathy * Has a clinical suspicious or diagnosis of tuberous sclerosis complex characterized by one of these; known affected parent, previously diagnosed cardiac rhabdomyoma, hypomelanotic macules, forehead fibrous plaque, shagreen patch, retinal phakoma, or known polycystic kidneys * A contraindication to vigabatrin or corticosteroid such as recent varicella or herpes zoster infection, gastrointestinal hemorrhage etc. * Thai language ability of the parents or guardians is that they may not understand what is being requested of them. * Predictable lack of availability of follow up
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Cessation of spasms | Assessed during Day 14 to Day 42 after treatment. | Defined as no witnessed spasms (either clusters or single spasms) from Day 14 to Day 42 inclusive. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Electroclinical response | Between Day 14 and Day 21. | the cessation of spasms with the addition of absence of hypsarrhythmia (BASED score \< 2) on the Day 14 EEG. Valid Day 14 EEGs will be undertaken between Day 14 and Day 21 inclusive. |
| Extended electroclinical response | Between Day 42 and Day 49. | Electroclinical response with the addition of absence of hypsarrhythmia (BASED score \< 2) on the Day 42 EEG. Valid Day 42 EEGs will be undertaken between Day 42 and Day 49 inclusive. |
| The time taken to absence of spasms | Day 1 to Day 14 | Duration for clinical cessation of spasms after initiation treatment |
| Electrographic response | Assessed during Day 14 and Day 43 after treatment. | Disappearance of hypsarrhythmia defined by Burden of Amplitudes and Epileptiform Discharges (BASED) scoring system \< 2 at Day 14 and Day 43 after treatment. |
| Adverse reactions | Day 1 to Day 14, from Day 15 to Day 42, and from Day 43 to 4 months into the trial | Each adverse event will be evaluated by the principal investigator to determine whether in their view it is an adverse reaction. If considered an adverse reaction, it will be reported by using the standard classification. |
| Epilepsy outcome at age 18 months | From Day 42 to age 18 months | Epilepsy status and antiepileptic drugs (AEDs) will be recorded by using the following categories: 1) Infantile spasms (clusters of spasms), 2) Any other epileptic seizure including febrile seizures, and 3) Names of any preventive AEDs prescribed |
| Relapse of spasms | Day 42 to 3 months after treatment | Defined when a cluster of more than one spasm in reported after Day 42. No EEG is required. |
Countries
Thailand
Contacts
Primary ContactKullasate Sakpichaisakul, MD
Backup ContactSirorat Suwannachote, MD
Outcome results
None listed