Neurelis Files New Drug Application with the FDA for VALTOCO™ (Diazepam Nasal Spray), An Investigational Treatment for Pediatric, Adolescent, and Adult Epilepsy Patients

Neurelis, Inc. announced that the company has submitted a New Drug Application (NDA) with the U.S. Food and Drug Administration (FDA) for VALTOCOTM (diazepam nasal spray) as a treatment for epilepsy patients six years and older who experience increased bouts of seizure activity, also known as cluster or acute repetitive seizures. Earlier this year, the FDA provided conditional acceptance for use of the name “VALTOCO” for the product previously referred to in clinical development as “NRL-1”.

VALTOCO, Neurelis’ lead product candidate, is a proprietary formulation of diazepam incorporating the unique combination of a vitamin E-based solution and Intravail® absorption enhancement. The FDA previously granted Neurelis both Orphan Drug designation for VALTOCO in November of 2015 and Fast Track designation in December of 2016. There are over 3.4 million people with epilepsy in the United States with approximately 200,000 new patients diagnosed each year. Despite the availability of chronic, daily oral medications to control epilepsy, a significant number of these patients continue to experience seizures. Of these uncontrolled patients, about 170,000 are at risk for cluster or acute repetitive seizures.

Study Reveals New Therapeutic Target for Pediatric Tumor-Associated Intractable Epilepsy

Featuring the work of CURE Grantee Dr. Jeong Ho Lee

Pediatric brain tumors are characterized by frequent complications due to intractable epilepsy compared to adult brain tumors. However, the genetic cause of refractory epilepsy in pediatric brain tumors has not been elucidated yet, and it is difficult to treat patients because the tumors do not respond to existing antiepileptic drugs and debilitate children’s development.

A research team led by Professor Jeong Ho Lee of the Graduate School of Medical Science and Engineering has recently identified a neuronal BRAF somatic mutation that causes intrinsic epileptogenicity in pediatric brain tumors. Their research results were published online in Nature Medicine on September 17.

Seizure Outcomes Best With Complete Resective Surgery In Pediatric Patients With Polymicrogyria

Abstract

OBJECTIVE: Polymicrogyria (PMG) is a common malformation of cortical development. Many patients with PMG will have medically refractory epilepsy but the role of epilepsy surgery is unclear. The objective of this study was to assess the efficacy of surgical resection/disconnection in achieving seizure control in pediatric patients with PMG.

METHODS: A retrospective review of children undergoing epilepsy surgery for PMG between 2002 and 2017 at The Hospital for Sick Children in Toronto, Canada, was performed.

RESULTS: A total of 12 children aged 6 months to 17.8 years (median 8.8 years) underwent resective surgery (7 children) or functional hemispherectomy (5 children). Gross total resection or complete disconnection of PMG was carried out in 7 of 12 children. Follow-up duration was between 1 and 9 years (median 2.1 years). Nine children remained seizure-free at last follow-up. Complete resection or disconnection of PMG led to seizure freedom in 6 of 7 patients (86%), whereas subtotal resection produced seizure freedom in 3 of 5 patients (60%).

SIGNIFICANCE: We present one of the largest surgical series of pediatric polymicrogyria patients. Seizure outcomes were best with complete resection/disconnection of polymicrogyria. However, tailored resections based on electroclinical and neuroradiologic data can produce good outcomes and remain an appropriate strategy for patients with extensive polymicrogyria.

Diagnostic Efficacy And Study Quality Of Home Video Telemetry And Inpatient Video Telemetry For Epilepsy Are Similar In Pediatric Patients

Abstract

PURPOSE: Home Video Telemetry (HVT) combines ambulatory EEG with simultaneous video recording. No previous reports have compared HVT and inpatient video telemetry (IVT) in a purely paediatric population. This study compares HVT and IVT in this group in terms of diagnostic efficacy, recording quality and acceptability to parents/carers.

METHODS: 33 HVT and 29 IVT patients aged 1-17 years were included. Information regarding patient demographics, ictal capture, diagnostic utility, recording quality (e.g. video clarity, EEG artefacts) and parent/carer preferences was documented. Difficulties using HVT equipment were recorded.

RESULTS: 62% of IVT patients and 64% of HVT patients had typical attacks during the recording. 59% of IVT and 70% of HVT recordings were considered to have answered the referral question. Study quality was similar in both groups. In HVT studies the rate of equipment difficulties was 52%; problems included camera positioning and failure to turn on the infrared button at night. Diagnostic information was lost in 15% of patients. 76% of parents/carers of HVT patients would choose this investigation again.

CONCLUSIONS: The diagnostic efficacy and study quality of home video telemetry and inpatient video telemetry are similar in paediatric patients. Home video telemetry is acceptable to most parents/carers. User error may compromise the investigation in a minority of cases but did not impact on diagnostic utility. Adoption of home video telemetry investigation could provide an accessible and economic alternative to inpatient video telemetry.

Status Epilepticus Associated with Significant Mortality and Cost

Abstract

PURPOSE: To summarize the epidemiology, morbidity, mortality, and costs of status epilepticus (SE) in the pediatric population.

METHOD: Review of the medical literature.

RESULTS: The overall incidence of pediatric SE is roughly 20 per 100,000 children per year, with overall mortality of 3%. Underlying etiology is the biggest risk factor for SE, with symptomatic (acute > remote) etiologies associated with worse outcomes. The most common cause of SE in children is febrile SE, though this entity occurs primarily in early childhood. After a first episode, the risk of recurrence is similar to the risk after a first unprovoked seizure (25-40%). SE is expensive, regularly costing more than $10,000 per episode and often more than $100,000 for refractory cases.

CONCLUSION: Status epilepticus is not an uncommon neurologic emergency and depending on the associated etiology can carry significant morbidity, mortality, and cost especially if treatment is not performed in a timely manner.

Trend Of Increased Subsequent Epilepsy In Children With Recurrent Febrile Seizures: A Retrospective Matched Cohort Study.

Abstract

PURPOSE: Trends of epilepsy in children were correlated with febrile seizure (FS) in a previous retrospective study. In the present study, the authors obtained relevant data from a nationwide cohort database to investigate trends in subsequent epilepsy in children with a history of recurrent FS.

METHODS: A total of 10,210 children with FS comprised the cohort. The diagnosis date was used as the index date. A comparison cohort was randomly matched with each case based on age, sex, urbanization level, parents’ occupation, and index date. Cox proportional hazard regression was performed to estimate the hazard ratio and confidence interval of FS-associated epilepsy.

RESULTS: This retrospective cohort study included 7729 children with FS and a comparison cohort of 30,916 children. The incidence of epilepsy was 11.4-fold higher in the FS cohort than in the comparison cohort (5.67 vs. 0.49 per 1000 person-years, respectively). Compared with the comparison cohort, the epilepsy incidence rate ratio increased in children with admissions for FS, from 8.62 at 1 admission to 26.2 at ?2 admissions (95% CI 6.80-10.9, and 19.78-34.8, respectively; p for trend < 0.0001).

CONCLUSION: Febrile seizures may increase the risk for subsequent epilepsy in children. Recurrent febrile seizures increased the cumulative incidence of epilepsy.

Seizure Characteristics Are Related To Tumor Pathology In Children With Brain Tumors.

Abstract

OBJECTIVES: Brain tumors are found in 1-3% of children with newly onset of seizures. Understanding the impact of seizures on pediatric brain tumors and factors between seizures and brain tumors are crucial. This study aimed to evaluate the association of pediatric brain tumors on seizure occurrence and the relationships between seizures and the diagnosis and prognosis of brain tumors.

METHODS: In a cohort of 184 children with newly diagnosed brain tumors between August 2012 and September 2017, 56 patients with brain tumor-associated seizures were evaluated for their clinical characteristics, electroencephalography (EEG), tumor pathology, response to anti-epileptic drugs (AEDs) and their seizure outcome.

RESULTS: The prevalence of seizures in our cohort of children with brain tumors was 30.4% (n = 56/184). Supratentorial tumors were more commonly associated with seizures than were infratentorial tumors (89.3% vs. 10.7%; P < 0.01). Among patients with tumor-associated seizures, the tumors were most commonly located in the temporal lobe (32.1%), followed by the frontal (21.4%) and parietal lobes (16.1%) and other cortices. Thirty-four patients (60.7%) had benign tumor pathology and 22 patients (39.3%) had malignant tumor pathology; low grade astrocytoma (n = 15; 26.8%) was the most common histology type. Seizure onset at initial presentation was more frequently observed in the patients with benign tumors, whereas the patients with malignant tumors tended to have delayed seizure onset (P < 0.01). On EEGs, focal epileptiform discharges were more commonly seen in benign tumors, whereas focal and diffuse slow waves were most commonly associated with malignant tumors. Levetiracetam was the most commonly prescribed AED to treat brain-tumor-associated seizures.

CONCLUSIONS: In children with brain tumors, higher seizure frequency with normal neurologic examination was more prevalent in benign tumors, whereas less frequent seizures with focal weakness and signs of increased intracranial pressure were more indicative of malignancy. Delayed onset of seizures was more often observed in the children with malignant brain tumors. Seizure characteristics play an important role in relation to tumor biology and epileptogenesis in pediatric brain tumors.