Abstracts

Rationale: There are limited data describing the use of perampanel with mental or behavioral disorders. Here, I describe two case reports where perampanel was administered to patients with epilepsy who presented with uncontrolled seizures at Wayne Neurology and had a history of severe behavioral or mental health disorders. Patient 1 presented following hospitalization due to phenytoin toxicity, and was experiencing multiple monthly focal seizures with impaired awareness, and focal to bilateral tonic-clonic (FBTC) seizures. Patient 2 was experiencing focal seizures with impaired awareness and FBTC seizures (frequency unknown for both), and 3-4 generalized tonic-clonic (GTC) seizures a month. He was on parole after 30 years in prison for offences including assault, arson, and criminal sexual conduct. Methods: At presentation, Patient 1 was receiving 1000 mg/day valproic acid extended-release (ER) and 300 mg/day phenytoin. She was unable to work or maintain custody of her child due to bipolar disorder (treated with 1 mg risperidone twice daily). Despite transition to 1600 mg/day eslicarbazepine acetate and continuing to receive 1000 mg/day valproic acid ER, her seizures continued. At presentation, Patient 2 was receiving 750 mg levetiracetam twice daily, 97.2 mg phenobarbital twice daily, and 1200 mg/day oxcarbazepine. He was transitioned to 1600 mg/day eslicarbazepine acetate (replacing oxcarbazepine) and 200 mg lacosamide twice daily; phenobarbital was slowly tapered off over 6 months. However, his seizures increased upon discontinuation of levetiracetam. Results: For Patient 1 (Table), perampanel was titrated to 8 mg/day over 4 weeks; treatment was well tolerated with no adverse events (AEs). She experienced no further FBTC seizures but continued experiencing perimenstrual focal seizures with impaired awareness. Subsequent vagal nerve stimulator (VNS) placement ensured she remained seizure-free for 1 year. The psychiatric medication dosage has been maintained, and her bipolar disorder is well controlled. The patient has obtained custody of her child, can work full-time, and can drive. For Patient 2 (Table), perampanel titration to 8 mg/day occurred over 1 month, and a VNS was placed in parallel. FBTC seizures stopped, but the patient experienced two focal seizures with impaired awareness. After VNS titration, the patient remained seizure-free. Perampanel was well tolerated with no AEs. He has had no issues of aggression or agitation and not violated his parole. The patient has continued to receive quetiapine 200 mg twice daily. Conclusions: Perampanel can be an appropriate treatment for patients with severe behavioral or mental health disorders who are not seizure free on other ASDs. During titration and at higher doses of perampanel, patients must be monitored for atypical behavior. Further research is required.  Funding: Medical writing support, under the direction of Dr Matthew C. Holtzman, was provided by Chris Whittle, PhD of CMC AFFINITY, a division of McCann Health Medical Communications Ltd., Manchester, UK, funded by Eisai Inc., in accordance with Good Publication Practice (GPP3) guidelines.