Imad Michel Najm, MD

 We use the same strategy to treat partial-onset seizures that we do with generalized convulsive seizures. Even though some patients say, “Doctor, I have very small seizures. I just basically blank out for 20 or 30 seconds. I have some mild tremors in my hand,” or they say, “My seizures are happening only during nighttime and are very minor seizures that only my partner will see.” 

In this situation, any patient with partial-onset seizures should understand—I try to make it clear to them, without scaring them—that they are at risk. If we don’t control these partial-onset seizures, the patient is at risk of developing secondary generalized convulsive seizures. We all know that partial epilepsy could lead, be associated ,or express itself as convulsive seizures. That is a big and important detail that the patient should understand. We should take this into consideration when we are talking to the patient; we need to try to give them bigger incentives to not miss taking their seizure medication, to ensure better compliance with the treatment.

Perampanel is an excellent treatment option for patients with partial-onset seizures and primary generalized seizures. One of the biggest characteristics, or biggest pluses, of using perampanel to treat patients with epilepsy is the fact that it has a long half-life. Therefore, it is dosed once a day; it is cognitively neutral, and it does lead to seizure freedom. In particular, it leads to freedom from generalized convulsive seizures—primary generalized convulsive seizures and secondary generalized convulsive seizures—in a large percentage of patients. These are patients who are using this as the first treatment or patients who did not see results with more than 2 or 3 antiseizure medications. It does work, and it does lead to seizure freedom that is maintained over the longer term. This was shown in the phase 4 studies that were discussed in the last American Epilepsy Society Annual Meeting. The effect of the treatment persists beyond the first 2, 3, or 4 months of the typical phase 3 trial, for example.

When it is indicated and used to treat select patients and then started at a low dose and moving up slowly, perampanel—in my experience and for my patient population—has been very well tolerated. There have been minimal, if any, cognitive complaints, and there is excellent seizure freedom, in particular, from generalized convulsive seizures. I am talking about an experience that, for many patients, is more than a 5-year experience. It is a well-tolerated medication; it is easy to take and effective in controlling partial-onset seizures and generalized convulsive seizures with primary generalized convulsive seizures.

We know very well that seizures can be controlled for many patients with epilepsy. The main challenge is how to ensure compliance with the treatment. The factors that will affect compliance—we understand them much better. This includes the frequency of dosing the medications, the adverse effects of the medications, and the efficacy of the medication. That is why, when we have a medication like perampanel that has a longer half-life, is dosed once a day, that works on various types of epilepsy—including focal epilepsy and generalized epilepsy—with a very good adverse-effect profile and excellent efficacy, in particular against generalized convulsive seizures, that tool helps a sizable number of our patients who live with seizures, epilepsy, or recurrent seizures and convulsions.

There is a great deal of importance placed on compliance, and we must consider the factors that will make a person be more compliant. Compliance is attainable. Compliance can be had if we know how to choose a medication with simple dosing, long half-life, a good cognitive profile, and good efficacy. That is the most important message. This will be complemented by explaining to the patient about the reasoning behind continuous chronic treatment for epilepsy and the risks that we run should we miss medications or should we run into the noncompliance issue.

Videos

An overview of available treatment options in epilepsy treatment to increase patient compliance, and a deeper diver into the recent data from the phase 4 ELEVATE study of perampanel.  

Treatment Options for Partial-Onset Seizures 

It is always in our minds, as practitioners—when we are trying to come up with a treatment strategy for our patients with the diagnosis of epilepsy—to find the best option. As an epileptologist, when I think about it, I have to answer the first question: Is it epilepsy or not? If it is epilepsy, do I think this epilepsy is primary, generalized epilepsy? Is it partial epilepsy, or focal epilepsy? The third question I will try to answer is what type of seizures does the patient have, or what are their major seizures? For example, if the patient is having generalized convulsive seizures, that is quite different from focal seizures. Some medications are better against generalized convulsive seizures.

The second thing—generalized convulsive seizures—present a bigger danger to the patient because of complications and a significant increase in sudden unexplained deaths, and deaths in general, in these patients with epilepsy. Having gone through this initial assessment algorithm—I think about that every time I see a patient for the first time—the next question will be, what is the best medication? How do we choose the best medication? We choose the best medication based on multiple factors. Some are specific to the medication. Some are specific to the patient; it is an individualized thinking.

From the medication standpoint, I like to choose a medication dosed once a day if possible. I would like to choose a medication with a longer half-life. I like to choose a medication that works on generalized convulsive seizures, that are partially onset to secondary generalizations or are primary generalized convulsive seizures. At the same time, they do work for patients who experience focal or partial seizures. I would like a medication that does not interfere with others the patient is taking or will be taking. I would like a medication that is cognitively benign or cognitively neutral. This means it does not affect memory and cognitive function to the extent that the patient would be missing medications if they have these types of adverse effects. 

Of course, I would like for the patient not to experience an increase in weight. For many of our patients, almost all of us would be much more resistant to them taking medication with this type of adverse effect. Of course, if the patient has any other comorbid psychological conditions, we would make sure that the medication the patient is taking is not destabilizing to their mood. There are multiple factors. We also look at the medication while considering the type of seizures and epilepsy. At the same time, we try to find out what the patient profile is—from a medical standpoint, from a cognitive standpoint, and from a psychological standpoint. We try to blend these 2 together using a medication that has a longer half-life and is easier to take, rather than prescribing a medication with a shorter half-life, or 1 that needs multiple dosings per day.

To increase compliance, there are multiple strategies practitioners can take. No. 1 is to make sure we highlight, for the patient, that medications are extremely important to control seizures. If the patient does not take the medication or is not taking medication, they are at risk of being involved in car accidents. They cannot drive. If they do risk driving, they and others on the road are at a higher risk. The patient is putting themselves at risk of sudden unexplained death, and they may be prone to injuries from these seizures. 

It is very important that the patient tries to understand the seriousness of their condition and, at the same time, the consequences of continued seizures. This is a fine line; there is a fine line between highlighting the seriousness of a condition and trying not to scare the patient. This is No. 1: to make sure the patient understands why we are treating them and why epilepsy is a serious illness if their seizures are not controlled. Second, we make sure we explain, to the patient, that we do not cure epilepsy. We control seizures as long as we are taking the antiseizure medications. 

If we do not take the antiseizure medications once a day, we are at a risk for that day—the patient risks having their seizures come back. This is what we call breakthrough seizures. The third thing is that we have to make sure we emphasize, to the patient, that if they experience an adverse effect on a medication, we have ways to control this. To avoid the adverse effects or decrease the adverse effects, we start our patients at a lower dose and move up the treatment slowly, so we’ll be able to stop at a dose that, for the majority of patients, is well tolerated or better tolerated. It also has to be, at the same time, effective. To sum it up—the best way to get compliance from the patient is to make sure the patient understands why we are giving them a certain medication. Second, we must give them a medication with a long half-life and once a day dosing if at all possible. We have to make sure we inform the patient of our strategy, which is basically to start low and go up slow.

An expert neurologist outlines best practices to consider in epilepsy therapy to increase patient compliance.  

Best Practices for Patient Compliance in Epilepsy Treatment 

COVID-19 has interfered with almost every aspect of life, including taking medications as prescribed. The effect has been different depending on patients’ lifestyles and where they are in their lives. For example, in the cases of patients who are older, patients who are considered to be at a higher risk for complications from COVID-19, some have shown a higher incidence of missing doses of their medication. This is because, according to them, they ran out of the medication and nobody could deliver this medication to them. They were used to walking to the pharmacy or getting somebody to drive them to the pharmacy to pick up the medications. 

With COVID-19, these patients are much more careful about going out. In some situations, they do not want to be with other people—including the people who would take them. They can take a cab, an Uber, a Lyft, or whatever, but they still would miss these medications because they ran out of the medications. Of course, COVID-19 interfered with epilepsy in general. For some patients who had COVID-19, their seizures did increase. Taking medications that may be interfering with the antiseizure medication would also predispose them to have breakthrough seizures; therefore, they would need more acute help.

If we want to think about the impact of telemedicine in the time of COVID-19—it has been a major lifesaver for many of our patients. I will give you an example. During the early months of the pandemic in March and April of 2020, more than 98% of our patients at The [The Charles Shor] Epilepsy Center at Cleveland Clinic were seen and managed through telemedicine—98%.

Telemedicine made it easy for us to switch and transition many of our patients from in-person office visits to virtual visits almost overnight. It enabled us to ensure a continuity of care, a continuity of addressing the issues that some of our patients were dealing with. Part of the stress that came from COVID-19 was the fear that it instilled in the minds of many, particularly those with preexisting conditions, including epilepsy. Telemedicine enabled us to avoid any interruption to this continuity of care, to send patients prescriptions whenever they needed, to address some of these questions they would have, to determine whether a higher level of care was needed, and to get the patient to where they are supposed to be.

Now that we are in the later stages of the pandemic, where many of us feel more comfortable being in public, especially after being fully vaccinated, has this change affected our patients’ compliance or adherence to medication and overall epilepsy care? I do not think it did. Actually, it made some patients who would prefer in-patient visits more comfortable coming to the clinic. Some patients may have avoided being seen because they did not even have the means, in some situations, to connect with us through the virtual environment. Some patients really valued the direct interaction with their physician much more, so they may have postponed their care. In some situations, this may have resulted—I don’t have proof of this—in them not taking the medication as prescribed, or running out of medication in some of these situations. 

Now that we have this hybrid practice in our environment, it is about getting patients to do whatever they are comfortable with. Some patients tell me, “I’m so happy that I’m able to see you in person.” Others say, “You know what, I don’t know. Unless you tell me I need to come back to see you in person, I would feel more comfortable continuing my treatment this way forever.” This has given our patients more choices and more options for us to connect with our patients to make sure we are giving them the care they all need.

A discussion about the impact of coronavirus 2019 (COVID-19) on patient compliance with epilepsy therapy. 

Impact of COVID-19 on Epilepsy Treatment  

The reason we treat patients with epilepsy is to shut down their seizures—in other words, to achieve seizure freedom. We know that we do not have medications that will cure epilepsy; we have medications our patients can take to control these seizures and to keep the person seizure-free. Therefore, when we discuss medication or treatment with a patient, we always make it clear to them that the goal is to completely control the seizures. To control these seizures, the patient needs to take their medications as prescribed—once a day, twice a day, at whatever the doses are prescribed. We always make it clear to patients with new-onset epilepsy—the patient and their families—that treatment of epilepsy does not mean curing epilepsy. Treatment of epilepsy means controlling seizures, and that is our goal.

The most important part of controlling seizures in patients with epilepsy is compliance or adherence to the treatment that was prescribed by the treating physician. It is easier said than done—we cannot just to say that, “It is easy to be compliant with, and to be adherent to, the prescription that the patient was given.” We all know that, as human beings, we are subject to forgetting to do things that we take for granted or that we think of as part of a routine. Life is always unpredictable, and sometimes we are more prone to forget to take a particular medication or a dose of a particular medication. If we look to our patient population and we think about it, what are the possible factors that will make our patients more likely to miss a medication than to take the medication? These factors include, first, whether a patient is having a reaction to a medication. For example, if a patient, every time they take a medication, feels a little sleepy, tired, or slower in their movements, they will be less prone to take the medication. Particularly, this may occur if you tell the patient to take a medication in the morning and evening. They may avoid taking the medication in the morning hours, for example. Effects or adverse effects of medication are important.

The second factor is, how often is the medication dosed? Is it once a day, twice a day, 3 times a day? The more frequent the dosing of the medication per day, the more likely the patient will be missing medications. Therefore, they will be more prone to have seizures. The third factor that plays a role in nonadherence is if the seizures are not controlled. If a patient is taking a medication and they think, “This medication is not helping me,” they may have the misconception that they do not need the medication, or they may be able to miss a dose because they feel like they would be the same. They would be still having seizures and, therefore, avoiding adverse effects and simplifying their own regimen. 

In brief, I want to think about what would be the best scenario for a patient not to miss a seizure medication. First, I would try to give my patient medication that requires 1 single daily dose, offer them medication that is well tolerated, and hopefully that gives the patient the best chance of seizure freedom. If we have these 3 factors—we take them into consideration and address them during the process of designing a treatment protocol or a regimen for the patient—the likelihood of missing medication will be much less.

An overview of the goals of epilepsy treatment, seizure freedom, and the importance of patient compliance.  

Goals of Epilepsy Therapy and the Importance of Patient Compliance 

 The way we diagnose epilepsy is by taking a history of the patient’s spells or seizures. The definite diagnosis of epilepsy is the EEG, or the electroencephalogram. In particular, we look for the presence of what we call epileptic spikes. In some situations, when the diagnosis is not too clear, the more definitive diagnosis is based on a recording of seizures in the setting of, most commonly, the epilepsy monitoring unit. It is an inpatient admission, and includes the recording of seizures.

The indications for drug therapy are based on knowing how many seizures a patient has had. The other thing to consider is if there is any abnormality, either on a neurological exam, on the EEG, and on an MRI scan of the brain. If a person has 1 single seizure and the seizure is not triggered—that means out of the blue—the patient would have their first seizure and the patient’s neurological exam would show some abnormalities. Alternatively, the EEG would show epileptic spikes or epileptic activities, or the MRI would show a lesion in the brain that could be epileptic. These are situations in which we will treat, even after the patient has 1 single seizure. If the patient has a seizure that was triggered—because of a lack of sleep, severe stress, mild head trauma, infection, or something like that—if they have only 1 seizure and everything else is normal and that particular trigger is somehow avoidable, we may not need to start the treatment after the first seizure. We would start the treatment after 2 seizures, even if they were triggered because there is a higher risk of seizure recurrence in the long term.

We can never predict who is going to be resistant to starting the medication and who is going to be receptive to taking them. In the majority of cases, obviously the patient does not want to have epilepsy. If you tell them, “You have epilepsy,” they may to say, “I would prefer not to be on medications.” Thinking about the patients who really may be concerned about medications—these are patients who are part of the younger patient population. They may feel medications are going to decrease their cognitive functions, slow down their movements, and make them more sleepy—and therefore, less ability to live their life the way they want to.

Imad Michel Najm, MD, discusses  various factors to consider when diagnosing epilepsy in patients such as when to start drug therapy as well as patient resistance to medications. 

Epilepsy Diagnosis  

“It's going to be a game changer, where the physical confines of things are not going to be a limitation anymore. We're going to be able to reach out to the world, and the world will be able to reach out to us.”

Patients are accustomed to seeing doctors in-person, and vice versa. While the overall reaction to telemedicine has been positive from both patients and doctors, there is still a level of adjustment that comes with this non-traditional, virtual style of diagnosis and treatment.

Imad Najm, MD, director, Epilepsy Center, and vice chair, Neurological Institute for Strategy and Development, Cleveland Clinic, sees the vast potential of telemedicine and the impact it can have on the epilepsy community.

In addition to allowing for better access to those who are unable to travel to see specialist, telemedicine can have a direct impact on patient savings, from work hours lost to transportation fees and use of resources. This increased role of digital technology will change the practices doctors use for diagnosing patients. In an interview with 

, Najm detailed his prediction regarding the change in clinical practice with the implementation of telemedicine.

The director of the Epilepsy Center and vice chair of the Neurological Institute for Strategy and Development at Cleveland Clinic detailed the transition patients and doctors make from the office to telemedicine.

Imad Najm, MD: Transitioning to Telemedicine 

“It’s enabling people even 10 miles from where we are to take 10 minutes from their work schedule to come to a private room, connect with us using their cell phone, get the physician to see them, to alleviate some of their angst, and to help them.”

While not a new technology, telemedicine continues to revolutionize the way doctors can assess and treat patients all from the comfort and convenience of their own home or workspace. These virtual visits enable patients to receive specialty care regardless of their location, and also enable physicians to participate in the care of patients located at other institutions.

Imad Najm, the director of the Epilepsy Center and vice chair of the Neurological Institute for Strategy and Development at Cleveland Clinic, detailed how Cleveland Clinic is expanding the utilization of telemedicine to expand their scope of care.

Cleveland Clinic has been at the forefront of this technology, using it to care for patients across multiple clinic locations around the world. Telemedicine is also utilized for patient care discussions between remote physicians to review cases and treatment plans. In this interview with 

, Najm shared his excitement for this technology and what untapped potential it has for the future.

The director of the Epilepsy Center and vice chair of the Neurological Institute for Strategy and Development at Cleveland Clinic discussed the advanced application of telemedicine at Cleveland Clinic.

Imad Najm, MD: Taking Telemedicine to the Next Level 

“It may give some benefit to the patient, their family, their loved ones to at least give them at least a warning that this patient may be having a seizure or may have had a seizure.”

Wearable technology has continued to make inroads for detecting epileptic seizures, with one device currently FDA-approved. The devices can serve as warning systems for patients and caregivers, as well as a way for providers to track seizure trends over time. In an interview with 

, Imad Najm, MD, the director of the Epilepsy Center at Cleveland Clinic, detailed the important role that wearable technology can play in detecting seizures in patients with epilepsy.

While wearable technology has made strides, there are still shortcomings in the sensitivity of what it can and cannot detect that need to be improved upon. On one hand, patients whose seizures go unnoticed or underreported can be undertreated, and in the case of hypersensitivity, some movements may be wrongly flagged as seizure activity.If recorded incorrectly, it could cause unnecessary mobilization of emergency services.   

In the interview, Najm detailed the evolution of wearable devices and their ultimate potential for improving epilepsy care.

The director of the Epilepsy Center at Cleveland Clinic reviewed the role that wearable technology can play in detecting seizures in patients with epilepsy.

Imad Najm, MD: Impact of Wearable Technology in Epilepsy 

“The excitement about CBD doesn’t come from the epilepsy specialists, it actually comes from society and the community. They think that CBD is the best treatment for not only epilepsy, but many other things.”

Cannabidiol (CBD) has become one of the most sought after, highly discussed options for treating not only epilepsy but other disabling conditions. Although it is a proven and FDA-approved treatment for Lennox-Gastaut and Dravet syndrome, epilepsy specialists should be cautious about prescribing it to anyone and everyone who seeks it. In an interview with 

, Imad Najm, MD, the director of the Epilepsy Center at Cleveland Clinic, described the pressure physicians face when patients fail to understand the purpose and utility of CBD.  

CBD is still in a very early stage of development and exploration for other types of epilepsies, and there is accumulating evidence that over-the-counter CBD products are often tainted or misrepresented compared with pharmaceutical grade CBD that physicians prescribe to their patients. Still, Najm remained positive that with more research, the possibilities of CBD treatment could expand in the future.

In the interview, Najm reviewed the complex dynamic that epilepsy specialists and patients share when discussing whether CBD is an appropriate treatment.

The director of the Epilepsy Center at Cleveland Clinic discussed why cannabidiol should be used cautiously in patients with epilepsy.

Imad Najm, MD: Utilizing CBD Effectively 

“Despite hundreds, if not thousands of publications showing the success of epilepsy surgery… unfortunately epilepsy surgery is not used to the extent that it should be used.”

According to Imad Najm, MD, director of the Epilepsy Center at Cleveland Clinic in Ohio, one of the biggest misunderstandings about epilepsy surgery is that it is experimental, when in reality it can be a life-changing treatment options for the thousands of patients with epilepsy who do not respond to medication. Ultimately, only about 1% of eligible patients undergo epilepsy surgery each year, despite its high rate of success.

Najm believes it is the responsibility of physicians, to help eliminate the stigma surrounding the procedure and recommend patients to be evaluated for surgery. Although the epilepsy community has been very vocal at medical conferences and other events about the safety and benefits of epilepsy surgery, statistically the rate of procedures performed each year remains low.

, Najm explained why epilepsy surgery should be considered among standard treatments for patients with refractory epilepsy.

The director of the Epilepsy Center at Cleveland Clinic explained why epilepsy surgery should be recommended and incorporated more.