Unmet Needs and Treatment of Relapsing-Remitting Multiple Sclerosis in Saudi Arabia: Focus on the Role of Ofatumumab.

Treatment-pattern data suggest that some patients with multiple sclerosis (MS) in the Kingdom of Saudi Arabia (KSA) may not be receiving optimal treatment. A virtual meeting of ten expert Saudi neurologists, held on October 23, 2020, discussed unmet needs in relapsing-remitting MS (RRMS), and the role of ofatumumab as a suitable treatment in the KSA. Multiple unmet needs were identified: poor quality of life, with high rates of depression and anxiety; a negative impact of MS on work ability; treatment choices that may compromise efficacy for safety or vice versa; inconvenient or complex dosage regimens; and limited access to patient education and support. Early use of highly effective disease-modifying treatments (DMTs) results in better patient outcomes than starting with less effective treatments and downstream escalation, but this strategy may be underutilized in the KSA. B cells are important in MS pathogenesis, and treatments targeting these may improve clinical outcomes. Ofatumumab differs from other B cell-depleting therapies, being a fully human monoclonal antibody that binds to CD20 at a completely separate site from the epitope bound by ocrelizumab, and being administered by subcutaneous injection. When compared with teriflunomide in two randomized, phase 3 clinical trials in patients with RRMS, ofatumumab was associated with significant reductions in annualized relapse rates, rates of confirmed disability worsening, and active lesions on magnetic resonance imaging. The incidence of adverse events, including serious infections, was similar with the two treatments. Ofatumumab is a valuable first- or second-line treatment option for RRMS in the KSA, particularly for patients who would benefit from highly effective DMTs early in the disease course, and for those who prefer the convenience of self-injection. Future research will clarify the position of ofatumumab in RRMS treatment, and comparative cost data may support the broad inclusion of ofatumumab in formularies across the KSA.

Consanguinity in patients with mesial temporal lobe epilepsy due to hippocampal sclerosis in a Saudi population.

OBJECTIVE: To investigate if there is an association between consanguinity and hippocampal sclerosis (HS) in the Saudi population. METHODS: A retrospective case-control study was conducted by assessing the prevalence of consanguinity in patients with pathologically proven HS, who underwent epilepsy surgery at King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia, between January 2004 and December 2015. We reviewed the medical records to extract data, which included; age, gender, duration of epilepsy, history of febrile seizure, family history of epilepsy in a first or second-degree relative, and pathology reports. RESULTS: A total of 120 patients, out of which 40 patients (65% male) having mesial temporal lobe epilepsy due to HS, and 80 controls (56% male) with cryptogenic epilepsy, were identified. Twenty-two patients (53.5%) in the HS group had a history of consanguinity. In the control group, 30 patients (37.5%) had a history of consanguinity. The odds ratio was 2.04 (95% confidence interval = 0.94 - 4.4, p=0.052). A family history of epilepsy was found in 28% of the patients with HS and 32.5% cryptogenic epilepsy. Only 8 patients (19.5%) with HS reported a history of febrile seizure. CONCLUSION: Our retrospective case-control study suggests that consanguinity might increase the likelihood of developing HS.

Impact of a family history of epilepsy on the diagnosis of epilepsy in Southern Saudi Arabia.

PURPOSE: Epilepsy can develop at any age for reasons that remain poorly understood. The aim of this study was to determine the impact of a family history of epilepsy (FHE) on the incidence and recurrence of seizures. METHODS: This retrospective study was conducted in Aseer central hospital, Abha, Saudi Arabia between January and June 2012. The medical records of 420 patients were analyzed to test the impact of FHE on the risk factors, etiology and diagnosis of epilepsy determined by magnetic resonance imaging (MRI) and electroencephalography (EEG). RESULTS: 420 patients were studied. Idiopathic epilepsy was seen in 140 patients (33%), symptomatic in 152 (36%), and cryptogenic in 128 patients (30%). FHE was seen in 113 patients (27%), which was associated with younger at the disease onset (15 years vs 20 years, p<0.05). Idiopathic epilepsy was seen more in patients with FHE (43% vs 30%, p value <0.05), and generalized seizures (primary or secondary) were also seen more in patients with FHE (51% vs 36%, p value <0.05). Abnormal EEG was also seen more in patients with FHE (79% vs 66%, p<0.05). Multivariate regression analysis showed that temporal epileptic discharges were the best predictor for the presence of FHE (p<0.05, OR=3.1, 95% CI 1.7-5.8), more than idiopathic epilepsy or younger age at epilepsy onset. CONCLUSIONS: FHE has a significant impact on epilepsy, its classifications, and the EEG findings, and may underlie the presence of a genetic etiology, which could be related to a high incidence of consanguinity seen in our population. Temporal epileptic discharges were the best predictor for FHE, which may suggest the presence of familial TLE.

Levetiracetam may worsen myoclonus in patients with juvenile myoclonic epilepsy: case reports.

Levetiracetam was approved for generalized and partial epilepsy in pediatric and adult population. It is also an effective antimyoclonus, but the evidence only supports its use as an adjunctive agent along with other antiepileptic drugs, such as sodium valproate, and it is commonly used in cases with juvenile myoclonic epilepsy. We report here 2 cases with juvenile myoclonic epilepsy who were switched from sodium valproate to levetiracetam to avoid the cosmetic or future teratogenic effect, but this switch was associated with exaggerated myoclonus despite escalating the dose of levetiracetam but resolved completely after reintroducing sodium valproate.

Ramsay Hunt syndrome with multiple cranial neuropathies in a liver transplant recipient.

Ramsay Hunt syndrome is an infection of the head and neck caused by varicella zoster virus involving the facial nerve; less commonly, other cranial nerves might be involved. We report a case of Ramsay Hunt syndrome in an immune compromised patient, with classic facial nerve palsy and ipsilateral ear vesicles, which rapidly evolved to involve multiple cranial neuropathies, and improved dramatically with antiviral therapy and corticosteroids. Varicella zoster virus should be considered as a cause of multiple cranial neuropathies in an immune compromised patient, and abrupt treatment with acyclovir should be initiated once this diagnosis is suspected.

Management of women with epilepsy. Practical issues faced when dealing with women with epilepsy.

Epilepsy is commonly encountered in neurology practice, affecting more than 50 million people worldwide, according to the World Health Organization reports. Management of women with epilepsy requires attention to some considerations including the hormonal changes and its impact on epilepsy, the interaction between oral contraceptives and antiepileptic drugs (AEDs), pregnancy, and the potential teratogenic risk associated with AEDs use during that period. Similarly, the effect of AEDs on bone health should always be considered, and measures should be taken to reduce the risk of osteoporosis given the fact that women in their menopause are at increased risk. Despite the considerable risk of teratogenicity with AEDs use in pregnancy, more than 90% of pregnancies will be uneventful.