Physician's Weekly Article - Conference Highlights: The 2009 AAN Annual Meeting

       The American Academy of Neurology held its 2009 annual meeting from April 25 to May 2 in Seattle. The features below highlight some of the news emerging from the meeting. For more information on these items and other research that was presented, go to www.aan.com.

      New Guidelines for Pregnancy in Women With Epilepsy

      The Particulars: About 500,000 women with epilepsy in the United States are of childbearing age. The majority of people with epilepsy have well-controlled seizures, are otherwise healthy, and expect to participate fully in life experiences, including pregnancy. Guidelines developed in collaboration with the American Academy of Neurology and the American Epilepsy Society were created based on reviews of scientific evidence.

      Data Breakdown: Women with epilepsy are not at substantially increased risk of having cesarean sections, late pregnancy bleeding, premature contractions, or premature labor and delivery. Women who are seizure free 9 months before becoming pregnant are unlikely to have any seizures during pregnancy. Pregnant women with epilepsy should consider having their blood tested regularly because levels of seizure medications in the blood tend to drop during pregnancy. Women with epilepsy are recommended to avoid valproate during pregnancy as it has been associated with an increased risk for fetal malformations and decreased thinking skills in children. If possible, women with epilepsy should not take more than one epilepsy drug at a time during pregnancy because this may increase risk for birth defects. Consider avoiding phenytoin and phenobarbital to prevent the possibility of decreased thinking skills in children. Women with epilepsy should be warned that smoking may increase the risk of premature contractions and premature labor and delivery during pregnancy.

      Take Home Pearls: It is relatively safe for women with epilepsy to become pregnant, but caution must be taken. Some medications for epilepsy should be avoided as they have been linked to birth defects.

      The Benefits of Optimizing Cholesterol & Blood Pressure Levels

      The Particulars: Previous studies have shown that lowering cholesterol and blood pressure is helpful overall in preventing stroke, but little is known if some risk factors play stronger roles than others. The Stroke Prevention by Aggressive Reduction in Cholesterol Levels, or SPARCL study, involved 4,731 patients who had a recent stroke or transient ischemic attack. Half received atorvastatin, a cholesterol-lowering drug, while the other half received placebo. The participants were followed for an average of 4.9 years.

      Data Breakdown: Optimal levels were defined as: LDL cholesterol <70 mg/dL, HDL cholesterol >50 mg/dL, triglycerides <150 mg/dL, and blood pressure <120/80 mm Hg. Patients who reached optimal levels in all four risk factors were 65% less likely to have another stroke when compared with those who did not reach optimal levels on any of the risk factors. Those who reached the optimal level on three risk factors were 38% less likely to have another stroke, and those who reached the optimal level on two risk factors were 22% less likely to have another stroke. Those who reached the optimal level on one risk factor were only 2% less likely to have another stroke than people who did not meet any of the optimal levels.

      Take Home Pearls: There appears to be a cumulative effect to lowering cholesterol and blood pressure in people who have had a stroke for preventing second strokes or heart attacks. Physicians and patients should collaborate to reach optimal LDL cholesterol, HDL cholesterol, triglyceride, and blood pressure levels. For each risk factor that is controlled at the optimal level, the risk of stroke and other major cardiovascular problems decreases.

      Emerging RLS Treatment Also Impacts Sleep

      The Particulars: Restless legs syndrome (RLS) affects about 10% of all people and is characterized by an urge to move the legs. It is generally accompanied by numbness, tingling, or burning sensations as well as an increase in symptoms during rest and partial, temporary relief from symptoms through activity. Symptoms, which progress with age, tend to worsen in the evening or at night, making it difficult for people with RLS to get adequate sleep.

      Data Breakdown: Pregabalin has been approved by the FDA to treat epilepsy, nerve pain, generalized anxiety, and fibromyalgia. A 12-week study assessed the safety and efficacy of pregabalin in 58 people with RLS; sleep was also analyzed. Nearly two-thirds of patients taking pregabalin had no RLS symptoms while on therapy. For symptomatic patients, the symptoms had improved by 66% while on pregabalin compared with the placebo group, which had symptoms worsen by 29%. The pregabalin group also spent more time in slow wave sleep and less time in lighter sleep stages when compared with the placebo group.

      Take Home Pearls: Pregabalin appears to be an effective treatment for RLS. It is a promising alternative to current therapies because of its superior effects on quality of sleep.

      Combination Therapy Beneficial in MS

      The Particulars: Methylprednisolone is a steroid drug that has typically been used only to treat acute multiple sclerosis (MS) attacks rather than use as an ongoing treatment. A study of 341 patients with relapsing-remitting MS was conducted in which patients received methylprednisolone plus interferon ß-1a or interferon ß-1a plus placebo. All participants had MS for an average of 3 years and had not yet received a disease-modifying drug. At the beginning of the study and again after 3 years, the size of lesions in the brain that signal disease activity was measured.

      Data Breakdown: For the intervention group, MS patients received methylprednisolone in monthly “pulses”—three doses over 3 days—in addition to regular weekly treatment with interferon ß-1a. Patients receiving methylprednisolone plus interferon ß-1a had 38% fewer relapses than those receiving interferon ß-1a plus placebo. The intervention group also improved slightly on tests of MS disability; scores for the placebo group decreased slightly. Among patients receiving methylprednisolone plus interferon ß-1a, the lesions stayed the same size or shrunk; the size of the lesions grew for those taking interferon ß-1a plus placebo.

      Take Home Pearls: Using a steroid drug for MS in addition to an MS drug may reduce the amount of disease activity more than using an MS drug alone. Patients receiving the combination approach had fewer MS relapses and improved slightly in disability.

      Assessing Leukemia Risk After MS Treatment

      The Particulars: Mitoxantrone is an immunosuppressant drug approved by the FDA for treatment of several forms of advancing multiple sclerosis (MS), having demonstrated efficacy in patients with secondary progressive MS who are having attacks. Previous studies have shown that MS patients treated with mitoxantrone have an increased risk of developing leukemia. In previous reports, acute leukemia has been shown to occur in 0.07% to 0.25% of MS patients taking mitoxantrone.

      Data Breakdown: In a retrospective investigation, researchers observed study participants who had at least one cycle of mitoxantrone treatment for at least 1 year. Patients who developed leukemia had more treatment cycles than those who did not develop leukemia (8.6 vs 7.2 cycles). They also had a greater cumulative dose of mitoxantrone. Leukemia occurred an average of 3 years after the first use of mitoxantrone and an average of 18 months after the end of treatment. About 0.74% of patients with MS receiving mitoxantrone developed acute leukemia.

      Take Home Pearls: The risk of developing leukemia as a side effect of mitoxantrone for MS may be higher than previously reported. The potential risk of leukemia should be carefully considered against the potential benefits of mitoxantrone. Prolonged and careful hematological follow-up to check for acute leukemia is vital in patients receiving mitoxantrone.