Lacosamide offers benefits as second-line treatment for refractory trigeminal neuralgia

Dr. Albert Munoz Wendrel

Data from a recently published retrospective descriptive cohort study show that treatment with oral lacosamide, apart from its previously reported potential for use as an intravenous salvage agent, may be useful in patients with trigeminal neuralgia (TN) in whom first-line therapy has failed. It suggests that it can be an effective alternative for

was announced in headache, Data were collected from 86 patients with refractory TN presenting to tertiary centers between 2015 and 2021. After failure of previous first-line therapy, the patient received lacosamide, with the dose determined by the attending neurologist based on clinical criteria and the patient’s comorbidities. The median time since he was diagnosed with TN was 4.6 years, and TN etiology was secondary in 19% of cases (n = 16).

Led by Albert Muñoz Wendrel, M.D., a neurologist at Belvich University Hospital, all patients in the study received carbamazepine or oxcarbazepine, two commonly used treatments for TN. I’ve tried it before. More than half of the cohort (54%) continued with one of these therapies as combination therapy, and 14% received lacosamide as monotherapy. His median initial daily dose of lacosamide was 100 mg (range, 50–400) and his median daily dose of maintenance dose was 200 mg (range, 50–600).

Analysis showed that two-thirds (66%) of patients achieved pain relief from their symptoms. Adverse events (AEs) found in 33% of the cohort were mild in all cases. The secondary endpoint of pain disappearance was achieved in 34% of his samples (n = 29). During follow-up, 44% (n = 38) of patients discontinued lacosamide treatment. Reasons included clinical improvement (34%, n = 13), ineffectiveness (45%, n = 17), and intolerance (21%, n = 17). n = 8). The researchers found no statistically significant differences in demographic and clinical data between responders and non-responders, except for the distribution of bilateral pain, where all three patients did not respond. .

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Comparing patients who received concomitant carbamazepine or oxcarbazepine (54%) with those who did not (46%), there was no significant difference in the proportion of patients achieving pain relief (67% vs. 65%; P. = .824) or in AE (35% vs 30%; P. = .653). The researchers noted that these findings add to the uncertainty as to whether lacosamide should be used as an alternative or an add-on to carbamazepine. “Further prospective studies are needed to draw clearer conclusions and better control for covariates such as reasons for dose adjustment or treatment change.”

Although no significant differences were observed between responders and non-responders, the investigators noted several predictors to consider when assessing the TN characteristics of each group. First, the majority of secondary TN was observed in non-responders (24% vs 16%; P. = .387), which was consistent with previous reports suggesting a poor treatment response in this group of patients.2

The study also showed that the presence of concomitant ongoing pain appeared to be more prevalent in non-responders (41% vs 28%; P. = .232), which was consistent with the previously reported poor response of this group of patients to medical and surgical treatment. Finally, the majority of patients with obvious neurovascular contacts that caused morphological changes on MRI were observed in the response group (23% vs 10%; P. = .242), while none of the three patients with bilateral pain distribution responded to treatment.

“These data pave the way for identifying the optimal patient profile for the use of lacosamide, which may be patients with typical TN and unilateral pure paroxysmal pain.” Expensive,” write Munoz Vendrell and others.

1. Munoz-Vendrell A, Tena-Cucala R, Campoy S, et al. Oral lacosamide for the treatment of refractory trigeminal neuralgia: A retrospective analysis of 86 cases. headache. Published online on April 10, 2023. doi:10.1111/head.14505
2. Di Stefano G, De Stefano G, Leone C, et al. Actual efficacy and tolerability of carbamazepine and oxcarbazepine in 354 patients with trigeminal neuralgia. Euro Jay Pain. 2021;25(5):1064-1071. Doi: 10.1002/ejp.1727

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