Epilepsy Essentials: Dravet Syndrome

What Are the Challenges of Dravet Syndrome?

Dravet syndrome (DS) can be very difficult to manage because of frequent and often prolonged seizures as well as comorbid developmental delays, intellectual disability, and communication impairments associated with the disease. Children with DS also often have challenges with sleep, and nutrition and feeding (ranging from swallowing problems to food sensitivity). Many children with DS are not correctly diagnosed until after they have tried multiple antiseizure medications (ASMs) and experienced drug-resistant epilepsy (DRE). For children with DS, these disabilities need to be addressed at home and at school, which can be particularly challenging, with children sometimes being labeled as oppositional or defiant, when in fact they are having seizures that prevent them from participating in their education.

Families caring for children with DS are highly impacted by their children’s needs, with 29% having left the workforce and many facing the issue of caregiver burnout.¹ Health care disparities and access challenges, such as lack of reimbursement for ASMs also create large challenges. Unless families are able to partner with a clinician who can advocate for reimbursement of treatments, children may go untreated, or families may face large out-of-pocket financial burdens .¹

For many with DS, by the time they and their family are being seen by a pediatric epilepsy specialist, they have been dealing with these challenges for some time, and all need to be addressed.

Can you Describe the Benefits of a Multidisciplinary Team?

Owing to the complexity of DS, a comprehensive care plan that addresses not only seizure reduction with ASMs but also support and care for comorbidities, educational difficulties, growth and nutrition, and social/emotional issues is needed. Thus, a multidisciplinary team is the best approach for management of DS. The ideal multidisciplinary team includes a social worker, pediatric epilepsy specialist physician, a nurse practitioner or other advanced practice provider, a care coordinator, and a specialty pharmacist. In my experience, having that ideal team in place reduced visits to the emergency department and improved quality-of-life for the family while being more cost-effective for use of health care resources.²

Specialty pharmacists can help with insurance paperwork and any needed advocacy for specific medications, and they can also work directly with the family. We have found that a follow-up call from a pharmacist who asks families if they filled the prescription, had any trouble administering the medication, or have questions about dosing or side effects improves adherence to treatment. Other members of the multidisciplinary team also play an important role in treatment adherence by addressing the patients and families’ needs holistically. This is essential because clinicians can prescribe any medicine they choose, but for treatment adherence, the family needs to have confidence in the treatment plan as well as having other needs met.

How Do You Work with Families on Choosing the Right ASMs?

There are 3 ASMs recently approved by the US Food and Drug Administration (FDA) specifically for treatment of seizures associated with DS: fenfluramine (approved in 2020), prescription cannabidiol (approved in 2018), and stiripentol (approved in 2018 for concomitant use with clobazam). Valproate, topiramate, and clobazam are also used to treat seizures associated with DS, although they are not specifically approved for this indication. It is critical not to use ASMs that block sodium channels (ie, carbamazepine, eslicarbazepine, fosphenytoin, lacosamide, lamotrigine, phenytoin, oxcarbazepine, or rufinamide) for DS because these ASMs can worsen DS.³

During shared decision making with patients and families, the choice of ASMs is guided by a risk-benefit analysis, family and patient concerns, administration methods, and dosing (Table). It is common to use 2 or more concomitant ASMs for DS to optimize seizure control. Often, patients’ insurance coverage will also affect the choice of ASMs because each insurance company has their own reimbursement criteria for ASMs. This is why it is essential for any clinician prescribing ASMs to carefully document use of and response to any ASM. If DRE is documented, it becomes more likely that other ASMs will be reimbursed, including the 3 ASMs approved by the FDA for the treatment of DS.

If an approved treatment for DS has high efficacy in an individual, it may be possible to discontinue or reduce dosages of other concomitant ASMs—except stiripentol and clobazam, which sometimes need to be continued to reach optimal seizure control. When considering reduction of concomitant ASMs, it is essential to act in a careful and controlled manner, reducing the dose of only 1 ASM at a time, and being sure to reduce doses slowly over time.

The Benefits of Profound Seizure Reduction

In a clinical trial of fenfluramine, 57.5% of patients taking fenfluramine experienced profound seizure reduction (≥75% reduction from baseline). In this same trial, patients taking fenfluramine experienced a median longest seizure-free interval of 20.5 days vs 8 days in the placebo group.^4-6

Higher seizure-reduction rates and longer seizure-free periods may improve quality of life, from the ability to participate in education and other therapies to family life. Improvements in cognition, particularly executive function among children and young adults; alertness; and sleep have been reported with fenfluramine treatment, along with improvements in speech, motor function, and mood.^7,8 Families report an increased ability to do things together, decreased family stress, and improved sibling relationships.⁸ It is also postulated that longer periods of seizure freedom and increased seizure reduction may reduce the risk of sudden unexplained death in epilepsy (SUDEP), which is higher in people with DS.

Some investigators have suggested that the profound seizure frequency reduction that occurs with newer DS treatments could change the standard of care regarding what is a reasonable seizure frequency reduction to expect with ASM treatment.⁹