PracticeUpdate Neurology February 2019

EDITOR’S PICKS 12

Lasmiditan: An Effective Acute Treatment for Migraine Neurology

Adherence With Psychotherapy and Treatment Outcomes in Patients With Psychogenic Nonepileptic Seizures Neurology Take-home message • This prospective cohort study evaluated the association between adherence with psychotherapy and outcomes in 105 patients with psychogenic nonepileptic seizures (PNES). Adherence was associated with decreased sei- zure frequency, better quality of life, and fewer emergency department visits. • Minority patients and patients with a history of childhood abuse were less likely to adhere to psychotherapy. Abstract OBJECTIVE We conducted a prospective cohort study of patients with psychogenic nonepileptic seizures (PNES) to examine the association between adherence with psychotherapy and outcomes, including signif- icant (≥50%) reduction in PNES frequency, PNES freedom, improvement in quality of life, and reduction in emergency department (ED) utilization. METHODS A total of 105 participants were referred to receive psychother- apy either at Brigham and Women’s Hospital or with a local therapist. We called participants at 12-24 months follow-up and obtained detailed follow-up data from 93 participants (89%). Participants were considered adherent with psychotherapy if they attended at least 8 sessions within a 16-week period starting at the time of referral. RESULTS Adherence with psychotherapy was associated with reduction in seizure frequency (84% in adherent group vs 61% in nonadherent, p = 0.021), improvement in quality of life (p = 0.044), and reduction in ED uti- lization (p = 0.040), with medium effect sizes; there was no difference in PNES freedom. The association between adherence and ≥50% reduction in PNES frequency persisted when controlling for potential confounders in a multivariate model. Psychotherapy nonadherence was associated with baseline characteristics of self-identified minority status (odds ratio 7.47, p = 0.019) and history of childhood abuse (odds ratio 3.30, p = 0.023).

Take-home message • The authors of this phase III placebo-controlled trial ran- domized adults with migraine to 100 mg or 200 mg of lasmiditan, a high-affinity, highly selective 5-HT1F receptor agonist, or placebo to treat their next migraine attack. More patients on active treatment were free of headache pain at 2 hours after dosing (32% with 200 mg, 28.2% with 100 mg, and 15.3% with placebo). Improvements in favor of the active arms were also seen in global impression of change and disability levels. No serious treatment-emer- gent adverse events were reported, and most common adverse events were dizziness and paresthesia. • The results indicate the safety and efficacy for lasmiditan in the acute treatment of migraine attacks in adults, many of whom had at least one cardiovascular risk factor. Codrin Lungu MD " Improvements in favor of the active arms were also seen in global impression of change and disability levels. " Abstract OBJECTIVE To assess the efficacy and safety of lasmiditan in the acute treatment of migraine. METHODS Adult patients with migraine were randomized (1:1:1) to a dou- ble-blind dose of oral lasmiditan 200 mg, lasmiditan 100 mg, or placebo and were asked to treat their next migraine attack within 4 hours of onset. Over 48 hours after dosing, patients used an electronic diary to record headache pain and the presence of nausea, phonophobia, and photophobia, one of which was designated their most bothersome symptom (MBS). RESULTS Of the 1,856 patients who treated an attack, 77.9% had ≥1 cardi- ovascular risk factors in addition to migraine. Compared with placebo, more patients dosed with lasmiditan 200 mg were free of headache pain at 2 hours after dosing (32.2% vs 15.3%; odds ratio [OR] 2.6, 95% confidence interval [CI] 2.0-3.6, p< 0.001), similar to those dosed with lasmiditan 100 mg (28.2%; OR 2.2, 95% CI 1.6-3.0, p< 0.001). Further- more, compared with those dosed with placebo, more patients dosed with lasmiditan 200 mg (40.7% vs 29.5%; OR 1.6, 95% CI 1.3-2.1, p< 0.001) and lasmiditan 100 mg (40.9%; OR 1.7, 95% CI, 1.3-2.2, p< 0.001) were free of their MBS at 2 hours after dosing. Adverse events were mostly mild or moderate in intensity. CONCLUSIONS Lasmiditan dosed at 200 and 100 mg was efficacious and well tolerated in the treatment of acute migraine among patients with a high level of cardiovascular risk factors. Lasmiditan Is an Effective Acute Treatment for Migraine: A Phase 3 Randomized Study. Neurology 2018 Nov 16;[EPub Ahead of Print], B Kuca, SD Silberstein, L Wietecha, et al. www.practiceupdate.com/c/77394

" Minority patients and patients with a history of childhood abuse were less likely to adhere to psychotherapy. "

CONCLUSIONS Our study is limited in that it cannot establish a causal rela- tionship between adherence with psychotherapy and outcomes, and the results may not generalize beyond the single quaternary care center study site. Among participants with documented PNES, adherence with psycho- therapy was associated with reduction in PNES frequency, improvement in quality of life, and decrease in ED visits. Adherence With Psychotherapy and Treatment Outcomes With Psy- chogenic Nonepileptic Seizures. Neurology 2019 Jan 04;[EPub Ahead of Print], B Tolchin, BA Dworetzky, S Martino, et al. www.practiceupdate.com/c/78679

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