Methyl prednisolone in infantile spasm journal presentation- A observational study

1. Welcome
Md. Shukur Ullah
DCH (student)
Bangladesh Institute of Child Health

2. Article Title
Short-term outcome of intravenous
methylprednisolone pulse therapy in
patients with infantile spasms

3. Source
Authors
Hye-Ryun Yeha, Min-Jee Kima, Tae-Sung
Koa, Mi-Sun Yuma, Su-Jeong You
Journal
Pediatric Neurology
DOI
10.1016/j.pediatrneurol.2017.03.017

4. Introduction
• An infantile spasm is an age-specific epileptic
disorder of early infancy that typically presents
with epileptic spasms occurring in clusters, a
disorganized high-amplitude interictal
electroencephalographic (EEG) pattern known as
hypsarrhythmia, and neurodevelopmental arrest
or regression.
• Several studies have reported that the duration of
hypsarrhythmia affects mental developmental
outcomes in infantile spasms.†

5. Introduction (contd.)
†Primec ZR, Stare J, Neubauer D. The risk of lower mental outcome in infantile spasms increases after three weeks of
hypsarrhythmia duration. Epilepsia. 2006;47(12):2202-2205.
Goh S, Kwiatkowski DJ, Dorer DJ, Thiele EA. Infantile spasms and intellectual outcomes in children with tuberous sclerosis
complex. Neurology. 2005;65(2):235-238.
*O'Callaghan FJ, Lux AL, Darke K, et al. The effect of lead time to treatment and of age of onset on developmental outcome at 4
years in infantile spasms: evidence from the United Kingdom Infantile Spasms Study. Epilepsia. 2011;52(7):1359-1364.
• The United Kingdom Infantile Spasms Study
(UKISS) has suggested that both early
cessation of spasms and a short lead time to
treatment reduce the total duration of the
epileptic encephalopathy and improve
developmental outcome.*

6. Introduction (contd.)
* Lux AL, Edwards SW, Hancock E, et al. The United Kingdom Infantile Spasms Study (UKISS) comparing hormone treatment with vigabatrin on
developmental and epilepsy outcomes to age 14 months: a multicentre randomised trial. Lancet Neurol. 2005;4(11):712-717.
† Wanigasinghe J, Arambepola C, Sri Ranganathan S, Sumanasena S, Attanapola G. Randomized, Single-Blind, Parallel Clinical Trial on Efficacy of
Oral Prednisolone Versus Intramuscular Corticotropin on Immediate and Continued Spasm Control in West Syndrome.
Pediatr Neurol. 2015;53(3):193-199.
• Although ACTH is considered the 1st line
treatment in several countries, there are
practical difficulties in terms of price and
availability specially in developing countries.*
• In addition, a previous study showed no
difference in control of spasms between the
ACTH and steroid groups, which means
ACTH treatment is not alone a persuasive
choice for infantile spasms.†

7. Introduction (contd.)
¹ Mytinger JR, Quigg M, Taft WC, Buck ML, Rust RS. Outcomes in treatment of infantile spasms with pulse methylprednisolone. J Child
Neurol. 2010;25(8):948-953.
• Although a small MPD trial was done previously
to determine the rate of remission, this is the first
study to investigate the safety and short-term
efficacy of pulse MPD therapy as the first-line
treatment of newly diagnosed infantile spasms.¹

8. Objective
• To investigate the short-term response to
intravenous MPD pulse therapy for the
treatment of infantile spasms.

9. Methodology (contd.)
Type of study
Prospective, open-label, uncontrolled
study
Place of study
1. Asan Medical Center Children’s
Hospital Seoul, Korea
2. Sanggye Paik Hospital, Seoul, Korea
Duration of study
From February 2014 to January 2016

10. Methodology (contd.)
Study population
14
Inclusion Criteria
Infants between the age of 2 to 11 months
presenting with infantile spasms and
hypsarrhythmia identified on EEG

11. Methodology (contd.)
Exclusion Criteria
1. Tuberous sclerosis
2. Patients previously treated with infantile
spasms
3. Patients with contraindications of steroid
therapy

12. Study Procedure
• Participants with newly diagnosed infantile
spasms intravenously received 30 mg/kg
methylprednisolone once daily for 3 days.
• Responders were then given a low dosage
(1 mg/kg two doses) of oral prednisolone,
which was rapidly reduced each week for 2 to
4 weeks.
• Non-responders were immediately transitioned
to other treatments including antiepileptic drugs
or a ketogenic diet.

13. Study Procedure (contd.)
• Sleep EEG recordings were performed before
and 2-22 days after the completion of MPD
pulse therapy. All patients treated with MPD
pulse therapy had laboratory monitoring of
electrolytes and blood sugar, blood pressure,
kidney function as well as electrocardiography.

14. Study Procedure (contd.)
• The outcome measurements were achievement
of freedom from spasms and tolerability as per
parental reports, improvement of
hypsarrhythmia after the completion of
therapy.
• Freedom from spasms was defined as the
cessation of spasms for at least 7 successive
days after therapy initiation within 14 days
after the MPD initiation.

15. Study Procedure (contd.)
• An electroclinical responder was defined as
patients who had clinical cessations of spasms
and resolution of hypsarrhythmia on EEG
within 3 weeks after completion of treatment.
• Spasm recurrence was referred to as
reappearance of spasms during first three
months after cessation of steroid.
• Time from therapy commencement to the
cessation of spasms and time from cessation of
spasms to recurrence were also measured.

16. Statistical Analysis
Software SPSS version 23
Statistical Analysis
 Statistical significance was defined as
P < 0.05
 The mean and standard error for
quantitative data and proportions for
categorical data were calculated.

17. Statistical Analysis(contd.)
 They used Fisher’s Exact tests for
comparisons of categorical baseline
characteristics and independent t-test in
relation to quantitative baseline
characteristics between complete responders
and non-complete responders.

18. Result
Table 1. Baseline characteristics of enrolled patients
Demographics Number of cases (Total N=14)
Sex, male N (%) 10 (71.4)
Age of onset, months 7.0 ± 2.5
Etiologies of spasms
Structural, N (%)
Periventricular leukomalacia N (%)
HIE N (%)
Hydrocephalus N (%)
Polymicrogyria N (%)
Lissencephaly N (%)
Genetic N (%)
Unknown N (%)
14 (100)
11 (78.6)
2 (14.3)
2 (14.3)
4 (28.6)
2 (14.3)
1 (7.1)
1 (7.1)
2(14.3)

19. Result (contd.)
Table 1. Baseline characteristics of enrolled patients
(contd.)
Demographics Number of cases (Total N=14)
Median treatment delay from initial spasms,
days
1.0
Spasm loads, clusters per day 3.6 ± 1.2
Gestational age at birth, weeks 34.4 ± 5.6
Prematurity, N (%) 6 (42.6)
Birth weight, kg 2.3 (1.2)
Developmental delay prior to onset of
infantile spasms, N ()%
13 (92.8)

20. Result (contd.)
Table 2. Comparison of electroclinical responders and
non-responders at 3 weeks after MPD therapy
Responders
(N=9)
Non-responders (N=5) P-value
Mean age of onset, months 6.1 ± 2.2 8.7 ± 2.6 0.11
Prematurity 3 3 0.58
Mean gestational age, weeks 35.1 ± 6.2 27.7 ± 5.3 0.26
Etiolology
Structural
Genetic/Unknown
7
2
5
1
1.00
Spasms load, clusters per day 3.1 ± 1.3 4.4 ± 0.9 0.04
Delay from diagnosis to
protocol entry, median (only
in patients with spasms)
1.0 (0-14) 2.0 (0-8) 0.68

21. Result (contd.)
In this study
• Nine of 14 patients (64.3 %) with spasms
achieved cessation of spasms and the mean
time to cessation of spasms was 3.0 days
(range, 1 to 14 days).
• All of 9 clinical responders exhibited resolution
of hypsarrhythmia on EEG.

22. Result (contd.)
• All five patients who failed to respond to
initial pulse MPD therapy received vigabatrin
as a second-line treatment; three out of these
patients (60.0 %) showed response to
vigabatrin. Of the remainders, none achieved
freedom from spasms during the 3 months of
follow-up.

23. Result (contd.)
• Spasms relapse was observed in 4 out of 9
patients (45.5%) who showed initial
electroclinical responses. In 4 children, the
recurrence occurred during the weaning
period with oral prednisolone (mean, 15.0
days; range, 14-18 days). Among patients
with recurrence, the ketogenic diet yielded
freedom from spasms in 2 patients, topiramate
was effective in 1 patient, and the other AED
treatments failed to control spasms among the
others.

24. Result (contd.)
• Of the infants who responded or failed on
MPD pulse therapy, the overall rate of
freedom from spasms or complete EEG
resolution at 3-month follow-up was 11/14
(78.6 %). Five out of 9 (55.6 %) MPD pulse
therapy-electroclinical responders remained
free of spasms. Three of 5 non-responders
who received vigabatrin as second-line
therapy were free of spasms at the 3-month
follow-up.

25. Result (contd.)
• Three of 4 patients who relapsed after MPD
pulse therapy received second or third-line
therapy and became free of spasms (2 with
ketogenic diet; 1 with topiramate) by the first
three months.

26. Result (contd.)
Adverse events
• Adverse effects were evaluated during MPD
pulse therapy and monthly by the first three
months.
• No deaths occurred after MPD pulse therapy and
no major side effects were noted. Irritabilities
were seen in 3 patients (21.4 %) and a lower
respiratory tract infection was observed in one
out of 14 patients (7.1 %).

27. Discussion
• This is the first study to investigate the safety and
short-term efficacy of pulse MPD therapy as the
first-line treatment of newly diagnosed infantile
spasms.
• A recent multi-center prospective study by Coryell
J et al. showed 55% spasm free rate in participants
receiving ACTH (150 IU/m² per day) as an initial
treatment and 39% spasms-free rate for oral
corticosteroids (40mg per day for 2 weeks) at 3
months.

28. Discussion
• Although ACTH is generally accepted as the
first-line treatment for infantile spasms, its
high cost and unavailability are the major
obstacles of the ACTH treatment.
• The short-term responses of oral prednisolone
at 2 weeks was 58.3% (Arambepola C et al.)
and 70% (Lux AL et al.) to UKISS protocol
prednisolone (40-60mg/day for 2 weeks) and
63% (Hussain SA et al.) to weight-based very

29. Discussion
high-dose prednisolone (8 mg/kg/day for 2
weeks then tapering off for 2 weeks), which is
comparable with 64.3% of responder rate
found in this study.

30. Discussion
• Mytinger JR et al. showed a 10 case series using
a course of intravenous MPD at a dosage of
20mg/kg for 3 days followed by a 2-month oral
prednisolone taper yielded spasms cessation and
hypsarrhythmia resolution in 50% of patients
within 14 days. In comparison to this study,
median treatment delay from initial infantile
spasms onset was 18.5 days and 70% of patients
had been started on an antiepileptic drug prior to
intravenous MPD.

31. Discussion
• To reduce the deleterious side effects of long
term corticosteroid therapy in young infants,
this study adopted the short term high dose
MPD pulse therapy as protocol for newly
diagnosed infantile spasms and the acute
adverse events were minor.
• A larger, long-term randomized prospective
study of intravenous MPD or a direct
comparison study to oral corticosteroids is
needed to determine the long term effects of
spasm control.

32. Limitation
• Only 2 center study.
• Small number of patients were included.
• Lack of a control group.
• Long term follow up was not done.

33. Conclusion
• MPD pulse therapy may be a safe and efficient
therapeutic choice for patients newly
diagnosed with infantile spasms.