Drugs DOI 10.1007/s40265-015-0514-7

ADIS DRUG EVALUATION

Lacosamide: A Review in Focal Seizures in Patients with Epilepsy Lesley J. Scott1

Ó Springer International Publishing Switzerland 2015

Abstract Lacosamide (VimpatÒ) is a functionalized amino acid available orally (as a solution or tablets) and as an intravenous infusion for use as monotherapy (only in the USA) or adjunctive therapy for the treatment of focal seizures in adult and adolescent (aged C17 years in the USA) patients with epilepsy. As adjunctive therapy to other antiepileptic drugs (AEDs), lacosamide provided effective seizure control and was generally well tolerated in adults and adolescents (aged C16 years) in randomized clinical trials and in the real-world setting. In clinical trials, adjunctive lacosamide provided significantly greater reductions in 28-day seizure rates than adjunctive placebo, with these benefits maintained after up to 8 years of therapy in open-label extension studies. Moreover, patients were effectively switched from oral to short-term intravenous adjunctive therapy at the same dosage, which may be particularly beneficial in situations where oral therapy is not suitable. Conversion to lacosamide monotherapy was superior to a historical-control cohort in patients with focal seizures converting from previous AED therapy. In the absence of head-to-head comparisons with other AEDs, the

The manuscript was reviewed by: G. K. Bergey, Department of Neurology, John Hopkins School of Medicine, John Hopkins Hospital, Baltimore, MD, USA; G. Krauss, Department of Neurology, John Hopkins University, Baltimore, MD, USA; F. Rosenow, Department of Neurology, Goethe-University Frankfurt, Epilepsy Center Frankfurt Rhine-Main, Frankfurt am Main, Germany; R. B. Shah, Department of Pharmacology, GMERS (Gujarat Medical Education and Research Society) Medical College and Hospital, Gandhinagar, Gujarat, India. & Lesley J. Scott [email protected] 1

Springer, Private Bag 65901, Mairangi Bay, 0754 Auckland, New Zealand

exact position of lacosamide relative to other AEDs remains to be fully determined. In the meantime, oral and intravenous lacosamide provides a useful option as monotherapy (only in the USA) or adjunctive therapy for the treatment of focal seizures in adult and adolescent (aged C17 years in the USA) patients with epilepsy.

Lacosamide: clinical considerations in focal seizures in epilepsy Selectively enhances the slow inactivation of voltage-gated sodium channels, with no effect on the fast inactivation of these channels Available as oral and intravenous formulations, with no dosage adjustment required when switching between these formulations As adjunctive therapy, reduces 28-day seizure frequency compared with placebo Conversion to monotherapy provides superior efficacy to a historical control cohort for Kaplan– Meier-predicted seizure-related exit criteria Efficacy maintained during long-term treatment Generally well tolerated as adjunctive therapy or monotherapy

1 Introduction Epilepsy is the fourth most common neurological disorder and clinically manifests as recurrent seizures due to abnormal excessive or synchronous neuronal activity in the

L. J. Scott

brain [1, 2]. Seizures are typically classified as generalized seizures involving bilaterally distributed networks, or focal seizures (previously termed partial-onset seizures) involving one hemisphere at seizure onset [3]. In the USA, approximately 2 million people are affected by epilepsy [2], with an estimated 65 million individuals affected globally [1]. The disorder is associated with significant morbidity and mortality and places a significant burden on healthpayer systems [1, 2]; in the USA, it accounts for $US15.5 billion of expenditure per year [direct (medical) and indirect (lost or reduced earnings and productivity) costs] [2]. Despite the availability of a number of antiepileptic drugs (AEDs), approximately one-third of patients do not achieve adequate seizure control [1, 4]. An improved understanding of the processes underlying the imbalance in normal excitatory and inhibitory mechanisms that modify neuronal excitability has led to the development of several new AEDs over the past decade [4, 5]. One such AED is the functionalized amino acid lacosamide (VimpatÒ), which was approved in numerous countries, including the USA and EU countries, as an adjunctive therapy for patients with focal seizures, and is newly licensed in the USA [6] for use as monotherapy in adults (aged C17 years) with focal seizures. This article reviews the clinical use of lacosamide as adjuvant therapy to other AEDs (as reviewed previously in CNS Drugs [7]) and as monotherapy in the treatment of focal seizures in epilepsy patients, with an overview of its pharmacological properties.

2 Pharmacodynamic Properties The exact mechanism of action by which lacosamide exerts its antiepileptic effects in humans remains to be fully determined [6]. In electrophysiological in vitro studies, lacosamide stabilized hyperexcitable neuronal membranes and inhibited repetitive neuronal firing by selectively enhancing slow inactivation of voltage-gated sodium channels without affecting fast inactivation [8]. By contrast, the AEDs carbamazepine, lamotrigine and phenytoin inhibit both slow and fast inactivation of voltage-gated sodium channels [8]. Although initial preclinical studies suggested that lacosamide may exert an additional mechanism of action by binding to collapsin response mediator protein 2 (CRMP-2; involved in neuronal differentiation and control of axonal growth) (as reviewed in CNS Drugs [7]), recent in vitro studies demonstrated that there appeared to be no specific binding of lacosamide to CRMP2 [8, 9]. In several animal models, including models of focal and primary generalized seizures, lacosamide treatment resulted in antiepileptic and antinociceptive effects [7].

Lacosamide treatment had no detrimental effects on sleep quality or daytime sleepiness in an open-label, multicentre study in healthy volunteers receiving lacosamide 300 mg/day [10]. At study end, there were no significant changes from baseline in median Wake After Sleep Onset times (primary endpoint), total sleep time or sleep efficiency. Oral lacosamide 400 or 800 mg/day did not prolong the corrected QT interval or have a clinically relevant effect on QRS duration in a double-blind study in 247 healthy volunteers [11]. However, lacosamide induced a small, dosedependent increase in the mean PR interval, with the time to maximum observed PR interval at steady state corresponding with the time taken (tmax) to attain maximum concentration. In the lacosamide 400 and 800 mg/day groups, the placebo-subtracted maximum increases in PR interval (at tmax) were 7.3 and 11.9 ms in healthy volunteers [11]. In clinical trials in patients with focal seizures, the placebo-subtracted mean maximum increase in PR interval with lacosamide 400 mg/day was 3.1 ms (also see Sect. 5) [6].

3 Pharmacokinetic Properties Bioequivalence between the oral tablet and oral solution formulations and between the oral tablet and intravenous formulations of lacosamide was established in studies in healthy male volunteers (as reviewed by Cawello et al. [12, 13]). In general, the pharmacokinetic profile of lacosamide was consistent between healthy volunteers and adults with focal epilepsy [12, 13]. There is no enantiomeric interconversion of lacosamide [6]. Lacosamide exhibits dose-proportional pharmacokinetics across the 100–800 mg dose range after single doses in healthy volunteers, with low inter- and intra-subject variability [6, 12]. Oral lacosamide is rapidly and completely absorbed in the gastrointestinal tract, with tmax attained in &1–4 h and an absolute bioavailability of &100 % [6]. Steady-state plasma concentrations of lacosamide are attained after 3 days of twice daily administration [6]. Lacosamide concentrations associated with a steady-state therapeutic dose are attained faster following a loading dose of 200 mg (intravenous or oral) than with a 10-day oral titration regimen (50 mg twice daily for 7 days, then 100 mg twice daily) [12]. Lacosamide exhibits minimal plasma protein binding (\15 %) and has a volume of distribution of &0.6 L/kg [6]. Lacosamide is metabolized primarily via demethylation to the pharmacologically inactive metabolite O-desmethyllacosamide [6]. Lacosamide is predominantly eliminated from the systemic circulation via renal excretion and biotransformation. After oral or intravenous administration,

Lacosamide: A Review

&95 % of radiolabelled lacosamide is eliminated in the urine, predominantly as unchanged drug (&40 % of the dose) and O-desmethyl-lacosamide (&30 %), with minimal excretion in the faeces (\0.5 %). Metabolism of lacosamide to O-desmethyl-lacosamide mainly involves cytochrome P450 (CYP) 3A4, CYP2C9 and CYP2C19. The elimination half-life (t‘) of lacosamide is &13 h and is not altered by different doses, multiple dosing or intravenous administration. The t‘ of O-desmethyl-lacosamide is 15–23 h [6]. Age (C18 years), gender, race and CYP2C19 polymorphism do not affect the pharmacokinetics of lacosamide [6]. Exposure to lacosamide is increased in patients with renal or hepatic impairment; in the USA, dosage adjustments are recommended in patients with severe renal impairment, those with end-stage renal impairment and those with mild or moderate hepatic impairment. The pharmacokinetics of lacosamide have not been evaluated in patients with severe hepatic impairment; lacosamide is not recommended in these patients in the USA [6]. Local prescribing information should be consulted regarding the use of lacosamide in specific patient populations in individual countries. Lacosamide appears to have a low potential for clinically relevant drug–drug interactions, including with commonly used AEDs (e.g. carbamazepine, gabapentin, levetiracetam, phenytoin, valproic acid) and drugs that undergo CYP-mediated biotransformation (e.g. warfarin, midazolam, omeprazole) [6, 12, 13]. In vitro studies indicate that lacosamide does not induce and/or inhibit various CYP enzymes [6]. It is also not a substrate for or inhibitor of p-glycoprotein. Studies in healthy volunteers and/or patients with focal seizures indicate that no clinically relevant drug–drug interactions occur when lacosamide is coadministered with other AEDs, digoxin, metformin, omeprazole, midazolam, oral contraceptives or warfarin [6].

4 Therapeutic Efficacy 4.1 In Clinical Trials 4.1.1 As Adjuvant Therapy in Short-Term Trials The efficacy of oral lacosamide as adjuvant therapy to other AEDs for the treatment of focal seizures in adults and/or adolescents (aged C16 years) with uncontrolled epilepsy was established in three large (n [ 300), doubleblind, multicentre, registration trials (SP667 [14], SP754 [15] and SP755 [16]) (previously reviewed in CNS Drugs [7]). Key eligibility criteria included a confirmed diagnosis of simple or complex focal seizures (±secondary

generalization), a history of focal seizures for C2 years despite AEDs (currently on stable dosages of 1–3 AEDs) and occurrence of at least four focal seizures/28 days, with no seizure-free period of [21 days, in the 8–16 weeks prior to randomization [14–16]. Key exclusion criteria included patients with primary generalized seizures within the previous 12 months or status epilepticus, and those with nonepileptic or psychogenic seizures within the previous 2 years [14–16]. In registration trials, adjunctive lacosamide 400 mg/day was associated with significantly greater improvements from baseline in 28-day seizure frequency and the proportion of patients achieving a C50 % reduction in seizure frequency (C50 % responder rate) than adjunctive placebo (coprimary endpoints) in intent-to-treat (ITT) and perprotocol analyses (Table 1) [14–16]. Results from a prioridefined pooled analyses of the ITT populations from these trials were consistent with those of the individual studies [17]. During the 12-week maintenance phase, median percentage reductions in 28-day seizure frequency in the lacosamide 200 (n = 267 ITT) and 400 mg/day (n = 466 ITT) groups were significantly greater than in the placebo group (n = 359) [33.3 and 36.8 vs. 18.4 %; p \ 0.05 and p \ 0.001, respectively], as were the C50 % responder rates (34.1 and 39.7 vs. 22.6 %; p \ 0.05 and p \ 0.001). The C75 % responder rate during this period was also significantly (p \ 0.001) higher in the lacosamide 400 mg/day (19.1 %), but not the lacosamide 200 mg/day group (13.5 %), than in the placebo group (9.2 %; a prioridefined secondary endpoint). The percentage of ITT patients who were seizure free throughout the maintenance phase in the lacosamide 200 and 400 mg/day and placebo groups were 2.2, 2.6 and 0.8 %, with respective mean increases in the percentage of seizure-free days during the maintenance phase in patients who entered this phase of 8.0, 11.6 (p \ 0.001 vs. placebo) and 6.1 % (a priori-defined secondary endpoints) [17]. Post hoc pooled analyses also confirmed the efficacy of adjunctive lacosamide in reducing seizure frequency, irrespective of whether or not patients had undergone surgery for epilepsy [17] or which concomitant AED regimen was utilized [17], including when traditional sodium channel blockers were included in the AED regimen [18]. Lacosamide also reduced seizure frequency by focal seizure subtype, with adjunctive lacosamide resulting in consistent reductions in complex-partial seizures and secondarily generalized partial seizures (sGPS) frequencies in exploratory post hoc analyses [19]. The 30-week (6-week titration and 24-week maintenance phases), open-label, multicentre SP954 study evaluated the efficacy of lacosamide 400 mg/day as adjunctive therapy in adult patients with epilepsy with uncontrolled focal seizures [20]. Patients were grouped into those receiving lacosamide as first adjunctive therapy to their

L. J. Scott Table 1 Efficacy of oral lacosamide as adjunctive therapy to other antiepileptic drugs in adult and adolescent (aged C16 years) patients with focal seizures. Results from multicentre phase II or III registration trials at the end of the 12-week maintenance phasea Treatmentb (mg/day)

Study

SP667 [14]

SP754 [15] SP755 [16]

No. of ITT/PP pts

Median reduction from baseline in focal seizure frequency/28 daysc (%)

Responder rated (% of pts)

ITT pts

PP pts

ITT pts

PP pts 38.1*

LCM 200

107/NR

26

BGD 21.5*

32.7

LCM 400

108/NR

39***

BGD 39.3****

41.1***

49.4****

PL

97/NR

10

21.9

21.2

LCM 400

201/NR

37.3**

39.6*

38.3**** (OR 2.8)

40.0****

PL

104/NR

20.8

21.7

18.3

18.4

LCM 200

160/140

35.3*

35.3*

35.0

35.0

LCM 400

158/121

36.4*

44.9**

40.5**

46.3**

PL

159/138

20.5

25.4

25.8

27.5

BGD between-group difference vs. PL, ITT intent-to-treat, LCM lacosamide, NR not reported, PL placebo, PP per-protocol, pts patients, OR odds ratio vs. PL * p \ 0.05, ** p B 0.01, *** p \ 0.005, **** p \ 0.001 vs. PL a

Preceded by a baseline phase and then a 4- or 6-week titration phase

b

Only recommended maintenance dosages are tabulated; two trials [14, 15] also included LCM 600 mg/day groups, which are not tabulated

c

Coprimary endpoint

d

Coprimary endpoint; percentage of pts achieving a C50 % reduction from baseline in the frequency of focal seizures

90

Percentage of patients

80 70

Group 1 (n = 68-72)

60

Group 2 (n = 249-261)

50 40 30 20 10 0 12-week seizure-free 24-week seizure-free 12-week responder rate rate rate

During the maintence phase Fig. 1 Efficacy of lacosamide 400 mg/day as first (Group 1) or later (Group 2) add-on therapy to other antiepileptic drug(s) in patients with focal seizures who completed B24 weeks’ maintenance therapy in the SP954 trial [20]. Responders had achieved a C50 % reduction from baseline in seizure frequency

first AED monotherapy (Group 1; disease duration of B2 years) and those adding lacosamide as later adjunctive therapy (Group 2; receiving 1–3 concomitant AEDs, after C2 previous AEDs and with a disease duration of C5 years). In this study, numerically more patients in Group 1 than in Group 2 were seizure free throughout the first 12 weeks of the 24-week maintenance phase (primary endpoint and timepoint) (Fig. 1) [20]. At the end of the

24-week maintenance phase, seizure-free rates remained numerically higher in Group 1 than in Group 2 in patients who completed this phase (Fig. 1). More than 50 % of patients in both groups achieved a C50 % reduction in seizure frequency after 12 weeks’ maintenance therapy (Fig. 1), with 66.7 and 36.0 % of patients in Groups 1 and 2 achieving a C75 % reduction in seizure frequency. Adjunctive lacosamide was also associated with clinically relevant and statistically significant (p \ 0.001) improvements from baseline in health-related quality of life (HRQOL), as assessed by Quality of Life Inventory in Epilepsy (QOLIE)-31-P total scores in Groups 1 and 2 [21]. In Groups 1 (n = 65) and 2 (n = 239–247), significant (p \ 0.05) improvements were seen for all QOLIE-31-P subscale scores, except for the medication effects subscale in both groups, the social function subscale in Group 1 and the emotional well-being subscale in Group 2. In Group 1 and 2, a clinically meaningful improvement was achieved by 49 and 43 % of patients, with clinically meaningful improvements in the individual subscale scores observed in 40–54 and 36–54 % of patients, respectively [20]. The efficacy of adjunctive oral lacosamide was maintained in patients who switched to the same dosage of intravenous lacosamide (200–600 mg/day) for 2 days in a pharmacokinetic, safety and tolerability study [22]. The general pattern and daily number of seizures experienced by patients in this study was consistent with those experienced in the previous 8 weeks in the open-label extension study [22].

Lacosamide: A Review

4.1.2 As Adjuvant Therapy in Long-Term Studies

4.1.3 Conversion to Monotherapy

The efficacy of adjunctive lacosamide was maintained and seizure frequency reduced during open label treatment for up to 8 years in extension studies [23–25]. These data were confirmed in pooled analyses of extension studies of the three registration trials, including in subgroup analyses in elderly patients (n = 33) [26], those receiving recommended lacosamide dosages (i.e. B400 mg/day; n = 363) [27] and by seizure type (i.e. complex partial seizures or sGPS; n = 1054) [28] (abstract presentations). For example, in the 5-year SP756 extension study of the phase III SP754 trial, patients initiated open-label treatment with lacosamide 200 mg/day, with the dosage adjusted (100–800 mg/day) based on efficacy and tolerability (total exposure to lacosamide was 767.4 years, with a median duration of treatment of &3 years) [24]. Overall, there was a median 48.5 % reduction in 28-day seizure frequency in the full analysis set (FAS; n = 307), with a C50 % responder rate of 48.2 %. For the 1- (n = 231), 2- (n = 193), 3- (n = 167) and 4-year (n = 88) completers, the median percentage reduction in 28-day seizure frequency from the baseline of the phase III trial was 53.4, 55.2, 58.1 and 62.5 %, respectively, with corresponding C50 % responder rates of 52.8, 56.5, 58.7 and 62.5 %. Seizure-free status was achieved by 3.0, 3.1, 1.8 and 1.1 % of 1-, 2-, 3- and 4-year completers, respectively [24]. In pooled analyses of the extension studies, adjunctive lacosamide was associated with significant improvements in seizure severity and HR-QOL from the baseline of the double-blind phase of the initial trial until 48 weeks in the extension phase (abstract presentation; no p-values reported) [29]. In an analysis of two phase III extension studies (SP756 and SP774; n = 607–614), for QOLIE-31 scores across all three extension studies (SP756, SP774 and SP615; n = 867), there were improvements in all subscales, which were statistically significant for seizure worry, social functioning and total score. At 48 weeks, improvements in QOLIE-31 scores were clinically meaningful in at least a third of participants; for both the seizure worry and social functioning subscales, 48 % of patients experienced clinically meaningful improvements. These improvements in seizure severity and HR-QOL were maintained after up to 5 years of lacosamide therapy [29].

The efficacy of conversion from stable dosages of 1–2 AEDs (for C28 days) to oral lacosamide monotherapy was evaluated in adults and adolescents (C16 years of age) with epilepsy with focal seizures in a historical-cohort controlled, double-blind, multinational trial (SP902; ALEXMT) [30]. Patients who experienced 2–40 focal seizures/ 28 days during the 8-week baseline phase were randomized to lacosamide 300 or 400 mg/day plus concomitant AEDs in the 3-week titration phase, after which they entered a 16-week maintenance phase (i.e. 6-week phase during which background AEDs were withdrawn and a 10-week lacosamide monotherapy phase). The median duration of lacosamide 400 mg/day monotherapy was 71 days. Key exclusion criteria included status epilepticus within the previous year, history of primary generalized seizures, cluster seizures within 8 weeks of study start, and any seizure-free period lasting C28 days, or more than five seizures of any type in 1 day during the baseline phase. The primary endpoint was the percentage of patients receiving lacosamide 400 mg/day who met C1 predefined seizure-related exit criterion (Table 2) by day 112 compared with the historical control exit percentage of 65.3 %, as assessed using Kaplan–Meier estimates. Analyses were conducted in the FAS population (n = 284; i.e. patients who completed the titration phase and started withdrawing background AEDs) [30]. By day 112, the proportion of patients meeting at least one exit criterion (30 %; 95 % CI 24.6–35.5) in the lacosamide 400 mg/day monotherapy group was superior to that of the historical control cohort, since the upper limit of the 95 % confidence interval was lower than the historical control exit percentage [30]. In the lacosamide 400 mg/day group, the mean time to meeting at least one of the seizurerelated exit criterions was 45 days. Based on the Clinician Global Impression of Change and the Patient Global Impression of Change scales, 75.4 and 74.3 % of lacosamide 400 mg/day recipients showed an improvement, with 60.5 and 61.2 % rated as very much or much improved on these respective scales. Results in the lacosamide 300 mg/day monotherapy group (n = 99) were consistent with those of the 400 mg/day group, including the proportion of patients meeting at least one exit criterion

Table 2 Seizure-related exit criteria in the ALEX-MT trial [30] 1. At least a twofold increase in average 28-day FS frequency vs. baseline phase 2. At least a twofold increase in consecutive 2-day FS frequency vs. highest 2-day FS frequency in baseline phase 3. Occurrence of a generalized tonic–clonic seizure if none had occurred in the 6 months prior to randomization 4. Prolongation/worsening of overall seizure duration, type, frequency, or pattern that necessitated study discontinuation 5. Status epilepticus or new onset of serial/cluster seizures FS focal seizure

L. J. Scott

(27.3 %; 95 % CI 18.4–36.3). In post hoc analyses of the lacosamide 400 mg/day group, 60.7, 34.3 and 14.9 % of those who completed the 10-week monotherapy phase (i.e. completers; n = 201) achieved a C50, C75 and 100 % reduction in 28-day seizure frequency, respectively, during the 10-week monotherapy phase. Conversely, 8 % of completers in this dosage group experienced a C25 % increase in 28-day seizure frequency during the 10-week monotherapy phase [30]. Lacosamide monotherapy was effective based on post hoc analyses of pooled data from the lacosamide 300 and 400 mg/day groups (safety set; all patients who received C1 dose of lacosamide) [abstract presentations] [31, 32]. In patients with 0–5, [5–15 and 15 years duration of epilepsy (n = 100, 120 and 205, respectively), the C50 % responder rates were 50, 42 and 39 %, respectively, during the 10-week monotherapy phase, with respective seizure-free rates of 12, 12 and 6 % [31]. During the 10-week monotherapy phase in patients who had previously discontinued 0, 1, 2 or C3 AEDs before study entry (n = 85, 72, 73 and 195, respectively), C50 % responder rates were 45, 42, 49 and 39 %, respectively, and seizure-free rates were 13, 14, 6 and 7 % [31]. The median seizure frequency/28 days during the baseline phase decreased during the titration phase by &50 % for all focal seizures, complex partial seizures plus sGPS and sGPS only, and was maintained at this rate during the withdrawal and monotherapy phases [32]. 4.2 In the Real-World Setting Adjunctive oral lacosamide therapy provided effective focal seizure control in the real-world setting in several large (n = 120–746) observational/postmarketing studies [33–36], including the non-interventional post-authorization VITOBA study [36], and retrospective [37–43] analyses. These studies were conducted in Germany [36], Romania [41], Scotland [35], Spain [33, 39, 40, 43], the UK [37], the USA [38, 42] and internationally [34]. Some of these data are only available as abstract presentations [34, 38, 39, 41, 42]. Discussion focuses on prospective, multicentre studies. During the final 3 months of the 6-month VITOBA study, in the modified FAS population (mFAS; n = 494; i.e. patients treated with adjunctive lacosamide within the approved dosage range up to 400 mg/day), 72.5 and 63.8 % achieved a C50 and C75 % reduction in 28-day seizure frequency compared with the 3-month retrospective baseline period and 45.5 % were seizure free [36]. Seizurefreedom rates during the final 3 months of the study in those aged C65 (n = 90) and \65 (n = 404) years were 56.7 and 43.1 %, with corresponding C50 % responder rates of 81.1 and 70.5 % (descriptive odds ratio 1.79; 95 %

CI 0.99–3.38). Adjunctive lacosamide improved seizure control during the final 3 months of the study in the mFAS population, irrespective of whether patients were treated by physicians at specialized epilepsy centres (EC), hospitalbased neurologists (HN) or office-based neurologists (ON). Seizure-freedom rates in the EC, HN and ON groups were 31.0, 38.0 and 50.9 %, respectively, with corresponding C50 % responder rates of 52.0, 60.0 and 80.2 %. Differences in efficacy may, at least in part, reflect differences in baseline patient characteristics (e.g. disease severity and duration, and treatment history), all of which suggest that EC patients were a more refractory patient population. Adjunctive lacosamide also improved seizure control during the final 3 months of the study in the mFAS population, regardless of the baseline concomitant AED used or whether concomitant AEDs were sodium or non-sodium channel blockers [36]. In the prospective, multicentre, Spanish RELACOVA study (n = 158), the C50 % responder rate after 12 months of adjunctive lacosamide in adult patients with refractory partial seizures was 46.8 %, with a seizure-free rate of 24.1 % (coprimary endpoints) [33]. At 12 months, C50 % responder (65.3 vs. 37.5 %; p = 0.001) and seizure-free (34.7 vs. 17.3 %; p = 0.017) rates were significantly higher in patients receiving concomitant non-sodium channel blockers (n = 49) at baseline than in those receiving concomitant sodium channel blockers (n = 104). At baseline, the mean time since disease onset was 23.5 years, the mean monthly seizure rate was 18.7 and most (93.7 %) patients had not achieved seizure control despite at least 2 AEDs (53.2 % had previously received 3–6 AEDs). The median dosage of lacosamide at 12 months was 324.5 mg/day, with a dosage range of 100–800 mg/day [33]. The majority patients with epilepsy converting to lacosamide monotherapy in the real-world setting were switching from lacosamide therapy plus another AED (41.2 %) or from another AED monotherapy (37.4 %) and 18.5 % were AED treatment-naive, based on a large (n = 746), retrospective US study of data from the IMS PharMetrics Plus health claims database [38]. During the 12 months’ follow-up after initiation of lacosamide monotherapy, 69.8 % remained on a lacosamide-based regimen.

5 Tolerability Adjunctive oral lacosamide was generally well tolerated in adult patients participating in clinical trials discussed in Sect. 4.1.1, with the majority of adverse events being mild or moderate in intensity [14–16, 20]. In a pooled analysis [44], 8, 17 and 5 % of patients in the adjunctive lacosamide

Lacosamide: A Review 35 30

Percentage of patients

Fig. 2 Pooled analysis [6] of treatment-emergent adverse events occurring in [5 % of patients in either adjunctive lacosamide group and with a higher numerical incidence than with adjunctive placebo in registration trials [14–16] in epileptic patients with focal seizures

Lacosamide 200 mg/day (n =270)

25

Lacosamide 400 mg/day (n = 471)

20

Placebo (n = 364) 15 10 5 0 Dizziness Headache

Nausea

200 mg/day, lacosamide 400 mg/day and placebo groups, respectively, discontinued treatment because of a treatment-emergent adverse event (TEAE). The most common (incidence [1 % in the lacosamide total group and greater than with placebo) TEAEs leading to discontinuation of lacosamide were dizziness, ataxia, vomiting, diplopia, nausea, vertigo and blurred vision [6, 44]. The most commonly reported TEAEs occurring in adjunctive lacosamide groups in phase III registration trials [14–16] were dizziness, headache, nausea and diplopia (Fig. 2) [6]. The overall adverse event profiles in lacosamide recipients were similar between male and female patients and between Caucasians and non-Caucasians [6]. Adjunctive lacosamide had a minimal effect on bodyweight in phase III trials, with mean changes in bodyweight with recommended dosages of lacosamide ranging from -0.2 to ?0.2 kg versus a 0.6 kg gain with adjunctive placebo [14–16]. Based on another pooled analysis of registration trials, serious TEAEs occurring with an incidence of C1 % in any treatment groups were dizziness (0, 0, 0 and 1.5 % in the lacosamide 200, 400 and 600 mg/day and placebo groups, respectively), nystagmus (1, 0, 0 and 0 %) and convulsion (1.1, 1.1, 0 and 0.8 %) [17]. Relatively few patients experienced abnormalities in liver function tests in clinical trials of adjunctive lacosamide therapy [6]. In a pooled analysis, alanine aminotransferase levels of C3 9 the upper limit of normal (ULN) occurred in 0.7 % of lacosamide recipients (n = 935) and 0 % of placebo recipients (n = 356). One healthy subject experienced hepatitis (transaminase levels [20 9 ULN) and nephritis (proteinuria and urine casts) 10 days after cessation of lacosamide. In this individual, transaminase levels returned to normal within a month without specific treatment, with the hepatitis/nephritis interpreted as a delayed hypersensitivity reaction to lacosamide [6].

Diplopia Vomiting

Blurred Somnolence Fatigue vision

Ataxia

Tremor

Long-term (C8 years) lacosamide therapy as an adjunct to other AEDs was generally well tolerated in extension studies and other studies discussed in Sect. 4.1.2. The safety profile with long-term adjunctive lacosamide therapy was consistent with that in short-term, double-blind trials, with most TEAEs being of mild or moderate intensity [23, 24]. In terms of adverse events of special interest (n = 370 evaluable), memory impairment occurred in 7.3 % of patients, cognitive disorder in 4.3 %, increased or decreased weight in 5.7 and 3.5 %, depression in 9.5 % and chest pain in 4.1 % after B8 years of adjunctive lacosamide [23]. One-third of patients experienced serious TEAEs, 21.6 % of these events were considered treatmentrelated, with the most frequent being convulsions (1.6 %) [23]. Support for the minimal/lack of effects of adjunctive lacosamide on cognitive function comes from a prospective open-label study (n = 33) [45] and a retrospective, realworld controlled study (n = 44 treated with lacosamide, 11 with lamotrigine and 15 with topiramate) [46]. Short-term adjunctive intravenous lacosamide (i.e. 30or 60-min infusion of 100–300 mg twice daily) as a replacement for long-term adjunctive oral lacosamide (at the same dosage) [22, 47] in adult patients with focal seizures or as a loading dose (15-min infusion of 200–400 mg) prior to initiating oral lacosamide in lacosamide-naive patients [48] was generally well tolerated in clinical trials. In general, TEAEs with intravenous lacosamide were similar to those observed with oral lacosamide, although intravenous lacosamide was associated with local adverse events such as injection site pain or discomfort (2.5 % of patients), irritation (1 %) and erythema (0.5 %) [6]. One patient experienced profound bradycardia (heart rate 26 bpm and blood pressure 100/60 mmHg), which rapidly resolved upon discontinuation of the 15-min infusion of lacosamide 150 mg; this patient was also taking a b-blocker [6].

L. J. Scott

During the conversion to monotherapy study, the safety profile of lacosamide monotherapy was similar to that observed in lacosamide adjunctive therapy trials [30]. With the exception of adverse events coded to convulsion, TEAEs occurred more frequently during the titration phase than during the lacosamide monotherapy phase and led to treatment discontinuation in 16.9 % of patients. Convulsion events (8.2 %) and dizziness (1.6 %) were the most common TEAEs leading to discontinuation of lacosamide. Serious advents were reported in 4 % of lacosamide recipients, with most (63 %) considered to be unrelated to lacosamide therapy; convulsion was the only such event to occur in more than one patient (occurred in five patients). Of the three deaths, none were considered treatment related [30]. In the real-world clinical practice setting, adjunctive lacosamide was generally well tolerated in studies discussed in Sect. 4.2 and in non-interventional post-authorization studies [36, 49]. In the 6-month VITOBA study (n = 571) [36], the most common treatment-related adverse events were fatigue (10.3 % of patients) and dizziness (8.8 %), with 10.6 % of patients discontinuing treatment because of TEAEs. Of note, in a post-authorization safety study (SP942), there were no increases in the incidences of predefined cardiovascular and psychiatric TEAEs with adjunctive lacosamide therapy compared with other adjunctive AEDs (abstract presentation) [49]. Predefined cardiovascular adverse events occurred in 0.8 % of patients in both the lacosamide and other AED groups, with none considered serious or leading to treatment discontinuation. Of these events, one case each of sinus bradycardia and atrioventricular (AV)-block were considered to be related to lacosamide treatment. Predefined psychiatric adverse events occurred in 4.1 % of adjunctive lacosamide recipients and 5.5 % of patients receiving other adjunctive AEDs, with depression being the most frequent (2.9 vs. 4.3 %). These events were considered to be serious in five patients, consisting of two cases each of depression or suicide attempt with adjunctive lacosamide and one case of depression with other adjunctive AEDs. Of the seven patients who died during the study (three deaths in the lacosamide group), none were considered potentially or possibly treatment-related [49]. In clinical studies and in healthy volunteers (Sect. 2), dose-dependent prolongation of the PR interval has occurred during lacosamide treatment [6]. In a pooled analysis of clinical trials in patients with epilepsy with focal seizures, asymptomatic first-degree AV block occurred in 0.4 % of 944 evaluable lacosamide recipients and no placebo recipients (n = 364) [6, 50]. With infusions at higher than recommended dosages of lacosamide, there have been two postmarketing reports of cases of seconddegree AV block occurring in patients who had a

significant cardiac history and were receiving concomitant metoprolol and amlodipine [51, 52]. No patients experienced atrial fibrillation or flutter in short-term investigational trials in epilepsy patients, although cases of such adverse events were reported in open-label trials in epilepsy patients and in postmarketing studies [6]. There was no increase in the incidence of syncope in lacosamide recipients compared with placebo recipients in short-term trials in epilepsy patients with no significant system illness; however, cases of syncope have been reported in openlabel trials in epilepsy patients who had a history of risk factors for cardiac disease and were taking drugs that slow AV conduction [6]. There may be an increased risk of suicidal thoughts or behaviour in patients taking AEDs, including lacosamide, for any indication [6]. The relative risk for suicidal thoughts and behaviour was higher in clinical trials in epilepsy patients than in clinical trials for other indications, but the absolute risk differences were similar. In clinical trials, treatment-emergent depression occurred in 2, 2 and 1 % of patients receiving adjunctive lacosamide 200 mg/day, lacosamide 400 mg/day or placebo, respectively [6]. After B8 years of adjunctive lacosamide, 0.8 % (three patients) of patients reported suicidal ideation and one patient attempted suicide [23]. In general, the risk of suicidal thoughts or behaviour appeared to be consistent between the various AEDs, including lacosamide, based on pooled analyses, with careful monitoring of patients recommended during AED therapy [6, 53].

6 Dosage and Administration Lacosamide is available in various countries worldwide, including the USA [6]. Prescribing information and/or indications may differ between individual countries, with this section focusing on the US prescribing information [6]. Local prescribing information should be consulted for detailed information, including contraindications, drug interactions, precautions and use in special patient populations. In the USA, lacosamide is indicated as monotherapy or adjunctive therapy in patients (aged C17 years) with focal seizures [6]. Intravenous lacosamide is indicated as a shortterm replacement when oral administration is not feasible. The initial recommended dosage of oral lacosamide (available as tablets and a solution) as monotherapy is 100 mg twice daily and for adjunctive therapy is 50 mg twice daily. The dosage should be increased at weekly intervals by 50 mg twice daily, based on efficacy and tolerability, up to the recommended twice-daily maintenance doses of 150–200 mg as monotherapy or 100–200 mg as adjunctive therapy. Alternatively, lacosamide may be

Lacosamide: A Review

initiated with a single loading dose of 200 mg, followed &12 h later by 100 mg twice daily and this dosage should be continued for 1 week; thereafter, the dosage may be incremented at weekly intervals by 100 mg/day, based on efficacy and tolerability, up to the recommended maintenance dosage of 300–400 mg/day [6]. Intravenous lacosamide may be administered as a 15–60 min infusion using the same dosing regimens described for oral administration, including the loading dose, with close monitoring of patients at risk of cardiac adverse events (Sect. 5) [6]. When switching from oral to intravenous lacosamide, the initial intravenous dosage should be the same as that used orally [6].

7 Place of Lacosamide in the Management of Focal Seizures in Patients with Epilepsy The management of epilepsy primarily targets achieving seizure freedom with minimal adverse events to enable individuals to lead as normal a life as possible, with AEDs forming the cornerstone of pharmacotherapy [5, 54, 55]. However, despite the availability of numerous AEDs, approximately one-third of patients remain resistant to current AED therapy, with many requiring combination treatment with more than one AED. For these nonresponsive patients, the target of therapy shifts to maximizing the reduction in seizure frequency and severity in the absence of toxicity [5, 54, 55]. The introduction of lacosamide in the USA is too recent for the drug to have been considered in the most recent 2004 American Academy of Neurology and American Epilepsy Society treatment guidelines for newer AEDs (e.g. gabapentin, lamotrigine, levetiracetam, pregabalin and zonisamide) for the treatment of focal seizures [56, 57]. According to the more recent 2012 International League Against Epilepsy report, in adult patients with focal seizures, level A evidence (i.e. the AED is established as efficacious or effective as initial monotherapy) is established for the use of carbamazepine, levetiracetam, phenytoin and zonisamide, with level B evidence (i.e. AED probably efficacious or effective as initial monotherapy) established for valproic acid [58]. In addition to efficacy and tolerability/safety factors of individual AEDs, the choice of an AED is dependent upon several factors including seizure and/or syndrome type, the age of the patient, the potential for drug–drug interactions with concomitant medications and prior AED therapy [56, 57, 59]. Lacosamide has a favourable pharmacokinetic profile, in terms of its linear pharmacokinetics, minimal protein binding, lack of/low potential for drug–drug interactions (including with AEDs that are commonly used as adjunctive therapy for focal seizures) and availability of oral and intravenous formulations (no dosage adjustment is

required when switching between formulations) (Sect. 3). Conversely, several older AEDs (e.g. the strong CYP enzyme inducers carbamazepine, phenytoin, phenobarbital) used for treating focal seizures reduce the pharmacological effects of concomitantly administered AEDs and other drugs that are substrates for the same CYP enzymes and, although other newer AEDs tend to interact to a lesser extent with concomitant AEDs, these agents are associated with drug–drug interactions with several other types of drugs metabolized by CYP enzymes [54, 55, 59]. In general, the exact mechanism(s) of action of AEDs, including lacosamide, is unknown or not fully elucidated [59]. In contrast to carbamazepine, lamotrigine and phenytoin, which alter both slow and fast inactivation of voltage-gated sodium channels, lacosamide selectively enhances the slow inactivation of voltage-gated sodium channels, thereby stabilizing hyperexcitable neuronal membranes and inhibiting repetitive neuronal firing (Sect. 2). As adjunctive therapy to other AEDs in patients (aged C16 years) with focal seizures, oral lacosamide 400 mg/day and, in general, 200 mg/day, significantly reduced 28-day seizure frequency compared with placebo in short-term clinical trials (Sect. 4.1.1), with these benefits sustained after up to 8 years of lacosamide treatment in extension studies (Sect. 4.1.2). Lacosamide also had beneficial effects on HRQOL in short- and long-term studies (Sects. 4.1.1 and 4.1.2). Pooled data from the pivotal trials indicated that adjunctive lacosamide provided effective seizure control irrespective of the concomitant AEDs used, whether or not the concomitant AED regimen included other sodium channel blockers or whether or not patients had undergone surgery for epilepsy (Sect. 4.1.1). As monotherapy in patients who converted from stable dosages of 1–2 AEDs, lacosamide provided superior efficacy to that of a historical-control cohort, based on the Kaplan–Meier-predicted exit threshold (Sect. 4.1.3). Several prospective and retrospective studies in the realworld clinical practice setting confirmed the efficacy of lacosamide (typically as adjunctive therapy to other AEDs) for focal seizure control in patients with epilepsy (Sect. 4.2). In the absence of head-to-head trials, the relative efficacy of adjunctive therapy with newer AEDs for the treatment of focal seizures remains to be fully determined. Lacosamide, as adjunctive therapy to other AEDs or when converting to monotherapy, was generally well tolerated in patients with focal seizures in clinical trials and in the clinical practice setting (Sect. 5). The nature and incidence of adverse events was generally consistent between males and females, between Caucasians and non-Caucasians and between lacosamide monotherapy and lacosamide adjunctive therapy. The tolerability profile of adjunctive intravenous lacosamide was also consistent with that of oral lacosamide, although intravenous lacosamide was associated with local adverse events, such as injection

L. J. Scott

site pain or discomfort, irritation and erythema. Most TEAEs were of mild to moderate intensity, with the most common being dizziness, headache and nausea. Of note, lacosamide had minimal effects on bodyweight. Globally, epilepsy is associated with significant costs from a societal and healthpayer perspective [54], with costs being an important consideration in determining the choice of treatment in contemporary healthcare systems. To date, no robust pharmacoeconomic analyses of the use of lacosamide in patients with focal seizures from the US perspective have been fully published. As reviewed previously [7], relative to standard AED therapy alone, adjunctive lacosamide was predicted to be dominant (i.e. less costly and more effective) from the US healthpayer perspective, with incremental costs per quality-adjusted life-year gained falling within prespecified willingness-to-pay thresholds. In conclusion, as adjunctive therapy to other AEDs, lacosamide provided effective seizure control and was generally well tolerated in epileptic patients with focal seizures in the clinical trial and real-world clinical practice settings. In clinical trials, adjunctive lacosamide provided significantly greater reductions in 28-day seizure rates than adjunctive placebo, with these benefits sustained after up to 8 years of therapy. Moreover, patients could be effectively switched from oral to short-term intravenous adjunctive therapy at the same dosage, which may be particularly beneficial in situations where oral therapy is not suitable. Lacosamide monotherapy was superior to a historical-control cohort in patients with focal seizures converting from previous AED therapy. In the absence of head-to-head comparisons with other AEDs, the exact position of lacosamide relative to other AEDs remains to be fully determined. In the meantime, lacosamide is a useful option as adjunctive therapy to other AEDs or as monotherapy for the management of focal seizures in patients aged C17 years with epilepsy. Data selection sources: Relevant medical literature (including published and unpublished data) on lacosamide was identified by searching databases including MEDLINE (from 1946) and EMBASE (from 1996) [searches last updated 12 November 2015], bibliographies from published literature, clinical trial registries/databases and websites. Additional information was also requested from the company developing the drug. Search terms: Lacosamide, Vimpat, epilepsy, seizures, partial, focal. Study selection: Studies in patients with focal epilepsy who received lacosamide. When available, large, well designed, comparative trials with appropriate statistical methodology were preferred. Relevant pharmacodynamic and pharmacokinetic data are also included.

Acknowledgments During the peer review process, the manufacturer of the agent under review was offered an opportunity to comment on this article. Changes resulting from comments received were made by the author on the basis of scientific and editorial merit.

Compliance with Ethical Standards Funding The preparation of this review was not supported by any external funding. Conflict of interest Lesley Scott is a salaried employee of Adis/ Springer, is responsible for the article content and declares no relevant conflicts of interest.

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