Vineet Punia, MD, MS

"We don’t know what has not been explored yet. Because we are getting more older people who are coming to our clinics, we need to continue to explore more.”

Generalized epilepsy is most commonly observed in children, adolescents, and young adults, but has had relatively limited research on its effects in the elderly population with the condition, especially as the general population continues to age. Through a single-center, cohort study, researchers found that a substantial number of elderly patients with generalized epilepsy evaluated in an epilepsy monitoring unit setting had late-onset epilepsy, which differs in seizure type from the early-onset population.

Led by Vineet Punia, MD, MS, the study characterized 30 elderly individuals diagnosed with generalized epilepsy on features such as seizure onset age, management, and seizure types. Four patients had reported never been on antiseizure medications and 20 (66.6%) had refractory epilepsy.

, claims that this data is just another example of how clinicians still do not have a full grasp of generalized epilepsy and how it is characterized. He sat down with 

to discuss these treatment gaps and where research needs to turn to next.

Alzahary M, Punia V. Generalized epilepsy in the elderly undergoing epilepsy monitoring unit evaluation. Presented at 2021 American Academy of Neurology Annual Meeting; April 17-22. Abstract P7.080

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The neurologist at Cleveland Clinic addressed aspects of care for elders with generalized epilepsy that need to be further researched. 

Treatment Gaps Among Elders With Generalized Epilepsy: Vineet Punia, MD, MS

"When we talk about generalized epilepsy, the typical picture that comes to mind is of young children, adolescents, and young adults. That’s when, in general, generalized epilepsy onset starts. Around 90% to 95% of patients who have generalized epilepsy are younger patients. It’s quite rare to have older patients with generalized epilepsy, especially new onset generalized epilepsy.”

American Academy of Neurology (AAN) Annual Meeting

, April 17-22, described the clinical features and management of elderly individuals with generalized epilepsy who underwent epilepsy monitoring unit evaluation. In an effort to fill this knowledge gap, researchers performed a single-center cohort study that included data on age of seizure onset, anti-seizure medication use, and seizure types.

The median age of epilepsy onset among 30 individuals was 16 (interquartile range, 6-56) years, while one-third (n = 10) of patients had late-onset generalized epilepsy. Generalized tonic-clonic seizures were experienced by 19 of 20 (95%) compared to 6 (60%) late onset patients (

= .03). Vineet Punia, MD, MS, neurologist, 

, was among the researchers involved with the work and claimed that it was shocking to see the number of patients diagnosed with onset of generalized epilepsy after the age of 50 years.

Punia sat down to describe his study in full detail, as well as the history between focal and generalized epilepsy and their prevalence in different age groups. He also stressed that his data should serve as a reminder to clinicians that not all late-onset epilepsies are focal.

The neurologist at Cleveland Clinic discussed how his data may change clinicians’ perception on the management and prevalence of generalized epilepsy in elders.

Characterizing Generalized Epilepsy in Elders: Vineet Punia, MD, MS

"You want to see the long-term outcomes in terms of cognition or what happens to cognition in patients who undergo RNS implantation. Similarly, we need more long-term data on the mood outcomes of how the mood disturbances play out in these patients because that’s important as well.”

Responsive neurostimulation (RNS) is a breakthrough surgical approach to treating seizures that are not controlled by medication. Patients are considered candidates for RNS when they have undergone comprehensive diagnostic testing that has localized 1 or 2 seizure foci but are determined not to be candidates for surgical resection for a given particular reason. To date, RNS has been used and validated in adults, but not the elderly.

Senior author Vineet Punia, MD, MS, and colleagues recently presented research at the 2021 

, April 17-22, which evaluated 57 patients, 12 (21%) of whom were 50 years or older at the time of RNS implantation. Eight (67%) of the older adults had at least 50% seizure reduction, of whom 3 (25%) became seizure-free. Notably, younger adults had more RNS related complications in comparison to older adults (4 versus 0; 

, feels as though observing cognition in these patients is the next steps in expanding the use of RNS. He sat down with 

to detail the advantages of RNS that are still unclarified to this point.

Zawar I, Mackow M, Aexopoulos A, Nair D, Punia V. The efficacy, safety and outcomes of responsive neurostimulation (RNS) therapy in older adults. Presented at 2021 American Academy of Neurology Annual Meeting; April 17-22. Abstract P7.057

The neurologist from Cleveland Clinic offered his insight into the areas that he believes responsive neurostimulation could provide benefit to patients that need further examination. 

Exploring New Ways of Using Responsive Neurostimulation in Epilepsy: Vineet Punia, MD, MS

"There’s always a concern for safety when we are operating on older individuals and implanting this device, which is a chronic device that they would carry around [for the rest of] their life. We found out that it was equally safe or, in fact, safer in the small cohort.”

2021 American Academy of Neurology (AAN) Annual Meeting

, April 17-22, data from a single-center, retrospective study of 30 elderly individuals with epilepsy revealed that responsive neurostimulation (RNS) is a feasible and safe therapy for this patient population who cannot undergo epilepsy surgery. To date, there has been little to no data reported on the safety and efficacy of RNS in the elderly.

Among the 12 (21%) patients in the cohort who were 50 years or older at the time of RNS implantation, 8 (67%) had at least 50% seizure reduction, of whom 3 (25%) became seizure free. In comparison, 23 (52%) of the younger adults had at least 50% seizure reduction. of whom 5 (11%) became seizure free. Lead author Vineet Punia, MD, MS, and colleagues noted in the abstract that multicenter, larger studies are needed to better understand the efficacy and utility of RNS in this patient population.

to discuss what his findings suggest, as well as what the next steps in research are for RNS in older adults.

The neurologist from Cleveland Clinic stressed the potential for responsive neurostimulation in older populations with epilepsy and the need for expanded research. 

Evaluating, Expanding on Responsive Neurostimulation in Older Adults: Vineet Punia, MD, MS

“The elevate study being the first of its kind where we are trying it as a monotherapy, or first adjunctive therapy, gives us a lot of hope that we will have new, very useful data in the future once the study is complete and analysis is done. The hope is that we find it to be safe and effective in terms of helping with seizure control.”

Data from the phase 4 ELEVATE study (Study 410; NCT03288129) presented at the

 American Epilepsy Society (AES) Annual Meeting

, December 4–8, 2020, demonstrated that overall, patients with partial-onset seizures (POS) or primary generalized tonic-clonic seizures (PGTCS) were compliant with perampanel (Fycompa; Eisai) treatment and that the therapy was well tolerated.

The ongoing 12-month, multicenter, open-label, phase 4 study is the first prospective study of perampanel administered as monotherapy or first adjunctive therapy in patients aged ≥4 years with POS, with or without secondary generalized (SGS) or PGTCS. (

editor’s note: PGTCS seizures are now officially referred to as genetic generalized tonic-clonic seizures; POS seizures are now officially referred to as focal-onset seizures.)

The data, presented by Vineet Punia, MD, MS, neurologist, Cleveland Clinic, showed that patients were compliant with using perampanel as monotherapy or as the first adjunctive treatment for all of these seizure types. Ultimately, the study findings showed that compliance rates of >90%, 80% to <90%, and 70% to <80% were reported by 69.2% (n = 9), 7.7% (n = 1) and 23.1% (n = 3) of the 13-patient cohorts, respectively. NeurologyLive talked to Punia in this interview to learn more about perampanel and the results of the trial to this point.

To view NeurologyLive’s previous coverage of the ELEVATE trial, click 

REFERENCE
Punia V, Klein P, Kumar D, Salah A, Malhotra M. ELEVATE study 410 initial results: Phase IV study of perampanel as monotherapy or first adjunctive therapy in patients aged ≥4 years with partial-onset or primary generalized tonic-clonic seizures. Presented at AES 2020 Annual Meeting; December 4–8, 2020. Abstract 766.

The neurologist from Cleveland Clinic discussed the potential of using perampanel as a monotherapy for patients with focal onset seizures. 

Vineet Punia, MD, MS: Initial Data from ELEVATE Trial of Perampanel for Focal Onset Seizures 

“Perampanel is a first of its class drug that has a very unique mechanism of action. It is a selective, non-competitive antagonist at the very center of the blood glutamate neurotransmitter system. So, it is a very unique mechanism of action. And based on that there is a lot of potential in its effect in controlling seizures in patients both who have focal onset epilepsy or generalized onset epilepsy.”

Data from the phase 4 ELEVATE study (Study 410; NCT03288129) presented at the 

American Epilepsy Society (AES) Annual Meeting

The ongoing 12-month, multicenter, open-label, phase 4 study is the first prospective study of perampanel administered as monotherapy or first adjunctive therapy in patients aged ≥4 years with POS, with or without secondary generalized (SGS) or PGTCS. 

(editor’s note: PGTCS seizures are now officially referred to as genetic generalized tonic-clonic seizures.)

The data, presented by Vineet Punia, MD, MS, neurologist, 

, showed that patients were compliant with using perampanel as monotherapy or as the first adjunctive treatment for POS, SGS, or PGTCS. Ultimately, the study findings showed that compliance rates of >90%, 80% to <90%, and 70% to <80% were reported by 69.2% (n= 9), 7.7% (n = 1) and 23.1% (n = 3) of the 13-patient cohorts, respectively. NeurologyLive talked to Punia in this interview to learn more perampanel and the trial. 

 previous coverage of the ELEVATE trial, 

The neurologist from Cleveland Clinic discussed initial data from Study 410 and patient compliance rates with perampanel treatment. 

Vineet Punia, MD, MS

Articles

Treatment Gaps Among Elders With Generalized Epilepsy: Vineet Punia, MD, MS

Characterizing Generalized Epilepsy in Elders: Vineet Punia, MD, MS

Exploring New Ways of Using Responsive Neurostimulation in Epilepsy: Vineet Punia, MD, MS

Evaluating, Expanding on Responsive Neurostimulation in Older Adults: Vineet Punia, MD, MS

Vineet Punia, MD, MS: Initial Data from ELEVATE Trial of Perampanel for Focal Onset Seizures

Vineet Punia, MD, MS: Phase 4 ELEVATE Trial of Perampanel for Partial Onset Seizures

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