Optimal Use of Perampanel in Elderly Asian Patients with Epilepsy: Expert Opinion

Figures & data

Box 1 Expert Recommendations on Perampanel Use in the Elderly

Dose optimization (the “start low and go slow” strategy)

● Starting dose: 1 or 2 mg/day

● Titration: increase daily dose by 1 mg every 3 or 4 weeks

● Maintenance dose: 4 mg/day

Key considerations prior to initiation

Comorbidities

● Psychiatric or behavioral disorders

-Start with 1 mg/day and uptitrate no faster than 1 mg every 4 weeks

-Monitor any sudden behavior change

● Dementia

-Consider increasing perampanel dose to 4 mg/day at an early stage if patient does not have comorbid psychiatric or behavioral disorders

● Cardiac comorbidities

-Perampanel can be safely used

● Renal impairment

-Mild: increase dose no more frequently than once every 3 or 4 weeks

-Severe: consider excluding perampanel

● Compromised hepatic clearance capability

-Consider excluding perampanel

● Undergoing hemodialysis

-Consider excluding perampanel

Concomitant medications

● Enzyme-inducing ASMs: consider higher perampanel dose

Managing AEs and maximizing tolerability

● If AEs occur during titration period: downtitrate to previous tolerated dose and uptitrate again at smaller increments than before

● If AEs occur during maintenance period: reduce dose until AE resolves and slowly titrate to effective and tolerated maintenance dose again

● Falls: real-world analyses have not found a significantly increased risk of falls in the elderly when the “start low and go slow” strategy is employed

● Somnolence and sleep disorders: somnolence can be mitigated by taking perampanel shortly before bedtime, as indicated; perampanel’s favorable effect on sleep architecture is likely to benefit patients who suffer from sleep disorders

● Psychiatric AEs and aggression: proactively monitor for psychiatric AEs, especially aggression, and adjust perampanel dose accordingly

● Patient and caregiver education: inform on correct way and timing of taking perampanel; reassure them AEs can be effectively managed and treatment should not be stopped without consulting their physician

Abbreviations: AE, adverse event; ASM, anti-seizure medication.