Recent Neurology Data Highlight Treatments to Avoid

Hans-Christoph Diener, MD, PhD


August 25, 2022

This transcript has been edited for clarity.

Dear colleagues, I am Christoph Diener from the University of Duisburg-Essen in Germany. Today I would like to share with you results from six interesting studies published in July 2022.

Risk for Neurodevelopmental Disorders With Antiepileptics During Pregnancy

We're all aware that some antiepileptic drugs are teratogenic, particularly valproic acid. But the use of antiepileptics during pregnancy may also cause autism or intellectual disability.

This was recently investigated in a huge database in Scandinavia comprising 4.5 million pregnancies followed up for 8 years after birth. The authors looked at similarly sized groups of > 20,000 children whose mothers had epilepsy and who were either exposed or unexposed to antiepileptic drugs during pregnancy.

They observed that the risk for autism and intellectual disturbances at the age of 8 years old was significantly higher if the mother took either valproic acid or topiramate. Investigators also noted a dose relationship, with higher doses of these two antiepileptic drugs having a stronger association with autism and intellectual disability.

This means that these two drugs should probably be avoided, if possible, during pregnancy.

No Role for Vitamin C in Treating Sepsis in the Intensive Care Unit

Several prior studies have reported different outcomes regarding the use of IV vitamin C in adults with sepsis receiving vasopressor therapy in the intensive care unit (ICU).

The next study, which was published in The New England Journal of Medicine, investigated high-dose vitamin C in 872 patients with sepsis in the ICU. These patients were randomized to receive either placebo or vitamin C at 50 mg per kg of body weight every 6 hours for 96 hours.

The study was not only negative for vitamin C, but it showed that it led to a higher risk for the primary endpoint of death or organ failure. Mortality was also significantly higher on high-dose vitamin C.

This marks the end of vitamin C for the treatment of sepsis.

Latest Guidelines on Monoclonal Antibodies for Migraine

This July also saw the arrival of new guidelines from the European Headache Federation on the use of monoclonal antibodies for the prevention of migraine.

I do not agree with the first conclusion of these guidelines, which is that these monoclonal antibodies should be the first-line treatment option. Although monoclonal antibodies are effective and have very few adverse events, my disagreement is simply due to reasons of cost. Furthermore, most healthcare systems will not reimburse monoclonal antibodies as the first choice.

The guidelines' authors also support the common advice that treatment with monoclonal antibodies should last for 12-18 months and then be paused to see what happens.

They also indicate that, most probably, if one of the monoclonal antibodies — for example, erenumab — is not effective, then it makes sense to switch to one of the other ones: galcanezumab, eptinezumab, or fremanezumab.

Identifying Triggers for Migraine Attacks

I think we all believe in the concept of triggers for migraine attacks, and we advise our patients to avoid them.

A recent study investigated this in 328 patients using a smartphone app that recorded migraine attacks on a daily basis alongside 38 possible trigger factors. The results were astonishing. On average, this study identified only 2.2 trigger factors per patient in 90 days. The most frequent triggers were neck pain, sleep disturbances, and anxiety.

This means that we really have to think hard about whether we still advise patients to avoid trigger factors.

Rituximab vs Dimethyl Fumarate in Multiple Sclerosis

The next study, which comes from investigators in Sweden, looks at relapsing-remitting multiple sclerosis (MS).

Scandinavian countries use rituximab, a drug that frequently works via B cells, for the treatment of this condition. However, the drug is not approved for the simple reason that it went off patent before studies were performed on its use.

Investigators compared rituximab 1000 mg initially followed by 500 mg every 6 months in patients with relapsing-remitting MS with dimethyl fumarate oral 240 mg twice daily. The rate of new MS recurrences in the next 24 months was 3% on rituximab and 16% on dimethyl fumarate.

Whether the positive results of this study will lead to rituximab being reimbursed by the health system, I am not sure.

Controversial Findings on Vitamin B12 in Amyotrophic Lateral Sclerosis

The last study I'd like to discuss is also the most controversial one.

Investigators from Japan analyzed ultra-high doses of vitamin B12 in patients with the early stages of amyotrophic lateral sclerosis (ALS) in a double-blind, placebo-controlled treatment period of 12 weeks. They found that the intramuscular injection of 50 mg vitamin B12 twice daily for 16 weeks led to a significant benefit in patients with ALS compared with placebo.

However, most experts say they don't believe the results. There are two major problems. First is the short treatment period of 16 weeks. Second is the more serious problem that high-dose vitamin B12 will discolor urine, and in this way, patients are no longer blinded. So, at the moment, most experts would not use high-dose vitamin B12 in patients with ALS.

Dear colleagues, ladies and gentlemen, I am Christoph Diener from the University of Duisburg-Essen in Germany, highlighting what you will also hopefully view as six interesting new studies.

Thank you very much for listening and watching.

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