Reducing risk of SUDEP

Virtual Special Editions are collections of targeted papers curated by a guest Editor. Here, Dr Dag Aurlien from the University of Bergen, author of the Editor’s Choice article in Volume 43, talks about SUDEP.

Sudden unexpected death in epilepsy (SUDEP) primarily affects young adults and in refractory epilepsy the lifetime risk has been estimated to be as high as 35 %. The current special edition includes a collection of articles highlighting the potentially modifiable risk factors. The featured article of volume 43 (Aurlien et al.) discusses the relationship between choice of antiepileptic drug therapy and SUDEP risk. Recently a review by Jones and Thomas summed up the scientific progress during the last 25 years in our understanding of the pathophysiological mechanisms, risk factors and awareness about SUDEP and concluded that so far no effective prevention has been proven.

However, the Editor`s choice paper in Volume 43 “The role of antiepileptic drugs in sudden unexpected death in epilepsy” argues that the common view that no antiepileptic drug (AED) can increase the risk of SUDEP should be changed taking into account that the safety and efficacy profiles of AEDs can depend largely upon the epilepsy syndrome in which they are being used and underlines that appropriate choice of AED therapy according to epilepsy syndromes and seizure types is key to reduce the risk.

In 1998 the scientific discussion about a possible association between particular AEDs and SUDEP was initiated by Timmings who reported a cohort of SUDEP victims in which a significantly higher proportion had been treated with carbamazepine (CBZ) compared to living controls with epilepsy.

Going back to the first report of the same cohort in 1993 reveals a possible explanation of the finding; a high proportion of the SUDEP victims had generalized genetic epilepsy in which CBZ can increase seizure frequency and thereby also the SUDEP risk. A mutation in the cardiac SCN5A gene was the first cardiac channelopathy identified in a SUDEP victim. The patient had idiopathic epilepsy and had been treated with lamotrigine (LTG) which inhibits the cardiac potassium ion current IKr. The possibility that the drug could have played a role contributing to a fatal arrhythmia in an individual predisposed for cardiac arrhythmias was discussed.

In summary, inappropriate choice of AEDs may increase the risk of SUDEP due to lack of AED efficacy or a direct effect in predisposed individuals.

  • The role of antiepileptic drugs in sudden unexpected death in epilepsy

    Taubøll and colleagues
    DOI: https://doi.org/10.1016/j.seizure.2016.11.005
    Vol. 43
    Open AccessPreview

  • Sudden death in epilepsy: Insights from the last 25 years

    Thomas and colleagues
    DOI: https://doi.org/10.1016/j.seizure.2016.10.002
    Vol. 44
    Open ArchivePreview

  • Sudden unexpected death in epilepsy: is carbamazepine implicated?

    Timmings
    DOI: https://doi.org/10.1016/S1059-1311(98)80020-4
    Vol. 7, Issue 4
    Open ArchivePreview

  • Sudden unexpected death in epilepsy: a local audit

    Timmings
    DOI: https://doi.org/10.1016/S1059-1311(05)80142-6
    Vol. 2, Issue 4
    Preview

  • New SCN5A mutation in a SUDEP victim with idiopathic epilepsy

    Gjerstad and colleagues
    DOI: https://doi.org/10.1016/j.seizure.2008.07.008
    Vol. 18, Issue 2
    Open ArchivePreview
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