Mitchel L. Zoler/Frontline Medical News
Dr. Josiane LaJoie
When drug treatment fails to produce seizure freedom, other options are resective or ablative surgery, diet, or a neurostimulation implant. “At no time in history have we had as many nonpharmacologic treatment options as we have today,” said Dr. Christopher T. Skidmore, a neurologist in the Comprehensive Epilepsy Center at Thomas Jefferson University in Philadelphia. “With diet or neurostimulation, you get seizure reduction without the adverse effects of addition additional drugs.”
Study results with three different diets indicate that they can each produce a roughly 50% cut in seizure rate in about half the patients who adhere to the diet. The ketogenic diet has the longest track record, but with a 90% fat content, it is notoriously difficult to stick with and requires that patients eat meals that often preclude eating with friends or family members or away from home. Adhering to a modified Atkins diet or a low glycemic load diet seems about as effective as a ketogenic diet while offering more food flexibility and a range of foods more compatible with group meals or meals outside the home, Dr. Skidmore said.
Mitchel L. Zoler/Frontline Medical News
Dr. Christopher T. Skidmore
Even though the modified Atkins and low glycemic load diets offer somewhat more flexibility, both remain a “paradigm shift in food consumption,” compared with what most Americans eat, and when compliance is poor they don’t work. “Diet doesn’t work when people cheat,” Dr. Skidmore noted.
Three forms of nerve stimulation have also shown efficacy for seizure reduction, he said: vagal nerve stimulation, responsive neurostimulation, and deep brain stimulation of the anterior nucleus of the thalamus. “All three devices have proven efficacy,” he noted. “Neurostimulation offers an alternative to medical therapy that does not require daily effort and compliance.”
Discussions with patients about diet, neurostimulation, and surgery options allow each patient to decide whether one or more of these might be a good option. “It takes a certain patient to follow a diet or want an implant,” he said. “There is no one right choice. You need to educate patients and help them make their choice,” Dr. Skidmore advised.
Dr. Harmon had no disclosures. Dr. Perucca has served as a consultant to and received honoraria from Biopharma Solutions, GW Pharma, Takeda, Sun Pharma, and UCB Pharma. Dr. Kwan has been a consultant to Eisai and Novartis and has received research funding from UCB. Dr. LaJoie had no disclosures. Dr. Skidmore has been a consultant to Supernus and a site principal investigator for NeuroPace.
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