Seizure Rescue Medication for Epilepsy

Overseen By Study Research Coordinator

Age: 18+

Sex: Any

Trial Phase: Phase 4

Sponsor: Martha Sajatovic

Must be taking: Anti-epileptic

Must not be taking: Opioids, Benzodiazepines

Disqualifiers: Glaucoma, Dementia, Suicidal, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Prior Safety Data This treatment has passed at least one previous human trial

Approved in 4 Jurisdictions This treatment is already approved in other countries

Compensation: Varies

Number of Visits: 10

30 Participants Needed

What You Need to Know Before You Apply

What is the purpose of this trial?

This trial aims to test a program called SMART-RM, which assists people with epilepsy in managing their seizures using rescue medication (such as Diazepam, Midazolam, Lorazepam, or Clonazepam). Participants will engage in group sessions and maintenance phone calls to learn about seizure management. The trial seeks adults who have epilepsy, experience frequent seizures, and are currently on anti-epileptic medication. Participants should have experienced at least five seizures in the past six months. As a Phase 4 trial, this research focuses on understanding how this FDA-approved and effective treatment can benefit more patients.

Will I have to stop taking my current medications?

The trial does not specify if you need to stop your current medications. However, it mentions that participants should still be experiencing seizures while on anti-epileptic medication, suggesting you may continue your current regimen.

What is the safety track record for these treatments?

Research has shown that seizure rescue medications like diazepam, midazolam, lorazepam, and clonazepam are generally safe for people. However, they may cause side effects such as sleepiness, dizziness, or mood changes.

The SMART program, part of the treatment under study, is already used to help people manage epilepsy by improving self-care. This program aims to be safe and effective in facilitating self-care.

Since this trial is in a later phase, earlier stages have shown that SMART RM is generally well-tolerated. This suggests it is likely safe, but participants should report any side effects they notice. ^{1 2 3 4 5}

Why are researchers enthusiastic about this study treatment?

Unlike the standard seizure rescue medications for epilepsy, which often involve pharmaceuticals like benzodiazepines, SMART RM offers a unique approach by focusing on education and peer support. This treatment is delivered through a series of interactive, web-based group sessions led by both a Nurse Educator and a Peer Educator. Researchers are excited about SMART RM because it emphasizes collaborative learning and ongoing support, potentially empowering patients to manage their condition more effectively and reducing reliance on medication alone.

What evidence suggests that the SMART RM program is effective for managing seizures in epilepsy?

Research has shown that self-management programs like SMART can help people with epilepsy improve their self-care. The SMART program, which participants in this trial will experience, aims to simplify self-care, crucial for those at high risk of seizures. Past studies found seizure rescue medications like clonazepam and diazepam nasal spray very effective in controlling seizures. Specifically, clonazepam worked well for 22 out of 32 patients with epilepsy, particularly for certain seizure types. Diazepam nasal spray has been helpful in stopping clusters of seizures and prolonged seizures. This evidence suggests that combining a self-management tool like SMART with effective rescue medications could be promising for managing frequent seizures in epilepsy. ^{1 2 4 5 6}

Who Is on the Research Team?

Martha Sajatovic, MD

Principal Investigator

University Hospitals

Are You a Good Fit for This Trial?

This trial is for adults with epilepsy who experience repetitive seizures. Participants should be willing to engage in a comprehensive self-management program, which includes education on using rescue medication (RM) effectively. They must commit to attending several virtual meetings and providing feedback.

Inclusion Criteria

Inclusion criteria for participants who will receive SMART-RM: Have received a previous diagnosis of epilepsy, Be adults ≥ age 18, While on a regimen of anti-epileptic medication, still be experiencing bouts of seizures (e.g. frequent break through or acute repetitive seizures) distinct from their usual seizure pattern, and, in the opinion of the study epilepsy clinician, may need benzodiazepine intervention for seizure control, Have experienced at least 5 seizures but not more than 100 seizures in the previous 6 months, Be able to speak and understand English, Be able to provide written, informed consent to study participation

Exclusion Criteria

Exclusion criteria for participants who will receive SMART-RM: Individuals who have had allergic reaction to diazepam or who have medical/psychiatric conditions that are contraindications to the use of diazepam, Individuals prescribed opioid medications, Individuals with acute narrow angle glaucoma, Individuals with known dependence on benzodiazepines or current benzodiazepine abuse, Actively suicidal/homicidal, Individuals with a diagnosis of dementia, Individuals who are unable to provide written informed consent to participate in study and who do not have a legally authorized representative or individuals who are unable to participate in study procedures, Pregnant women

Timeline for a Trial Participant

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Phase 1: Adaptation and Stakeholder Input

Participants engage with the community advisory board (CAB) to adapt the SMART program for Rescue Medication (RM) use, involving 2-3 Zoom meetings over 3 months.

12 weeks

2-3 visits (virtual)

Phase 2: Treatment and Engagement

Participants engage in 8 group-format sessions of SMART-RM, followed by 3 monthly maintenance sessions.

24 weeks

8 group sessions (virtual), 3 maintenance sessions (telephone)

Follow-up

Participants are monitored for changes in epilepsy self-management, self-efficacy, social support, stigma, quality of life, functional status, and depressive symptoms.

4 weeks

What Are the Treatments Tested in This Trial?

Interventions

• SMART RM
• Valtoco Nasal Product

Trial Overview

The study tests the SMART RM program, adapted to include rescue medication use for seizure management. Phase 1 involves adapting the program with participant input. In Phase 2, the effectiveness of this tailored SMART-RM will be tested over six months.

How Is the Trial Designed?

Group I: SMART RM Experimental Treatment 2 Interventions

The SMART-RM will consist of 8 group-format, 45-60 minute sessions (up to 11 participants per group), which will be collaboratively delivered by a Nurse Educator (NE) and a Peer Educator (PE). The intervention will be remotely delivered in a web-based format using a secure web teleconferencing system (such as Zoom) that will allow us to set up a virtual meeting room. Following the group-session series, participants will have 3 monthly telephone maintenance sessions lasting around 15 minutes. Maintenance session web/telephone calls will be made to study participants by a NE with experience in epilepsy and/or chronic health condition management.

SMART RM is already approved in United States, European Union, Canada, Japan for the following indications:

Approved in United States as Diazepam for:

• Acute treatment of seizures
• Status epilepticus

Approved in European Union as Midazolam for:

• Acute treatment of seizures
• Status epilepticus

Approved in Canada as Lorazepam for:

• Acute treatment of seizures
• Status epilepticus

Approved in Japan as Clonazepam for:

• Acute treatment of seizures
• Status epilepticus

Who Is Running the Clinical Trial?

Martha Sajatovic

Lead Sponsor

Trials

3

Recruited

110+

University Hospitals Cleveland Medical Center

Lead Sponsor

Trials

348

Recruited

394,000+

Published Research Related to This Trial

In a study of 32 epileptic patients, clonazepam showed substantial improvement in seizure control for 22 patients, particularly effective for myoclonus, petit mal absences, and partial complex epilepsy.

While clonazepam is considered the drug of choice for generalized infantile organic epilepsy, its effectiveness may decrease over time, and drowsiness is the primary side effect reported.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Treatment of epileptic seizures with clonazepam. A reappraisal. Fazio, C., Manfredi, M., Piccinelli, A.[2019]

In a study involving 175 patients with seizure clusters, the nasal spray formulation of midazolam (MDZ-NS) was effective, achieving seizure termination in 55% of episodes after a single dose and 80.2% after a second dose, indicating strong efficacy in an outpatient setting.

The treatment was generally well tolerated, with 40.4% of patients experiencing treatment-emergent adverse events, primarily nasal discomfort and somnolence, but no serious safety concerns like respiratory depression or signs of drug dependence were reported.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Safety and efficacy of midazolam nasal spray in the outpatient treatment of patients with seizure clusters: An open-label extension trial. Wheless, JW., Meng, TC., Van Ess, PJ., et al.[2020]

Clonazepam is effective for treating childhood minor motor seizures and petit mal seizures that do not respond to other medications, but it is less effective for infantile spasms, although it may help if steroids fail.

While clonazepam can cause side effects like lethargy and ataxia, these are often temporary; however, some children may experience increased aggressiveness or hyperactivity, which could require stopping the medication.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

The utility of clonazepam in epilepsy of various types. Observations with 22 childhood cases. Nogen, AG.[2017]

In a study of 50 adults with epilepsy, rectal diazepam was effective in stopping breakthrough seizures in 90% of cases, indicating its strong efficacy as a rescue medication.

While most patients experienced somnolence (drowsiness) as a side effect, no serious adverse events were reported, suggesting that diazepam rectal gel is generally well-tolerated and could enhance the quality of life for those with epilepsy.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Effectiveness of diazepam rectal gel in adults with acute repetitive seizures and prolonged seizures: a single-center experience. Fakhoury, T., Chumley, A., Bensalem-Owen, M.[2013]

Three approved rescue therapies for treating seizure clusters in the U.S. are diazepam rectal gel, midazolam nasal spray, and diazepam nasal spray, with diazepam rectal gel being effective but potentially socially uncomfortable for adults and adolescents.

Midazolam and diazepam nasal sprays offer a rapid and socially acceptable alternative to rectal administration, allowing for easier self-administration during seizure clusters.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Rescue Treatments for Seizure Clusters. Kotloski, RJ., Gidal, BE.[2022]

Clobazam, a 1,5-benzodiazepine, has been shown to significantly reduce seizure frequency by 65% in patients with refractory epilepsy, making it an effective adjunctive therapy.

While clobazam is generally well tolerated with minimal cognitive impairment, it can cause sedation in some patients, and about 36% may develop tolerance over time, necessitating careful management of dosage and withdrawal.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Current status of the 1,4- and 1,5-benzodiazepines in the treatment of epilepsy: the place of clobazam. Robertson, MM.[2022]

Seizure clusters, which are acute repetitive seizures, affect about 1.2% of the U.S. population and require prompt treatment to prevent serious complications; however, up to 80% of adult patients do not use rescue medications like benzodiazepines, which are the standard treatment.

Long-term clinical trials have shown that intranasal benzodiazepines, such as midazolam and diazepam nasal spray, are effective and well-tolerated for treating seizure clusters, with mild to moderate adverse events and no reports of respiratory depression, highlighting their safety and ease of use for patients and caregivers.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Treatment of Seizure Clusters in Epilepsy: A Narrative Review on Rescue Therapies. Becker, DA., Wheless, JW., Sirven, J., et al.[2023]

Rescue therapies like diazepam rectal gel, midazolam nasal spray, and diazepam nasal spray are crucial for stopping seizure clusters and preventing progression to more severe conditions, with benzodiazepines acting as positive allosteric modulators of GABAA receptors to reduce neuronal excitation.

Midazolam and diazepam in nasal spray form provide a socially acceptable and rapid alternative to rectal administration, making them more convenient for adults and adolescents who may have reservations about rectal treatments.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Rescue therapies for seizure clusters: Pharmacology and target of treatments. Gidal, B., Detyniecki, K.[2022]

Intranasal rescue medications for seizure clusters, such as midazolam nasal spray, are easier and faster to administer than rectal or intravenous options, leading to shorter seizure durations.

Despite their effectiveness and safety, rescue medications are underutilized due to patient and caregiver perceptions, highlighting the need for better education and seizure action plans to improve their use.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Overcoming barriers to the management of seizure clusters: ease of use and time to administration of rescue medications. O'Hara, K., Dewar, S., Bougher, G., et al.[2023]

Clonazepam is an FDA-approved benzodiazepine anticonvulsant effective for various types of seizures, with a biological half-life of 22 to 32 hours, allowing for sustained therapeutic effects.

While it is effective, clonazepam can cause side effects like drowsiness and ataxia, which are often dose-related and may improve over time; therefore, it is recommended to start with a low dose and gradually increase.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Clonazepam. A review of a new anticonvulsant drug. Browne, TR.[2019]

Citations

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SMART is an evidence-based epilepsy self-management program aimed at reducing barriers and maximizing facilitators to self-care in high-risk PWE.

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Future opportunities for research in rescue treatments - PMC

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withpower.com/trial/phase-4-epilepsy-2-2024-6dcde

Seizure Rescue Medication for Epilepsy

In a study of 32 epileptic patients, clonazepam showed substantial improvement in seizure control for 22 patients, particularly effective for myoclonus, petit ...

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Findings in the study demonstrate the benefit of diazepam nasal spray use for both termination of acute seizure clusters and prolonged seizures ...

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sciencedirect.com

sciencedirect.com/science/article/abs/pii/S1525505025000721

Development of a self-management tool for individuals with ...

SMART is an evidence-based epilepsy self-management program aimed at reducing barriers and maximizing facilitators to self-care in high-risk PWE.