Infantile Spasms Respond Poorly to Topiramate Monotherapy

Objective: To determine the rate of infantile spasms (IS) remission with topiramate monotherapy. Methods: We retrospectively analyzed the rate of clinical remission for all IS patients treated with topiramate monotherapy from January 2009 to March 2014. For responders,the post-treatment electroencephalogram (EEG) was reviewed to assure electrographic remission. Clinical remission was assigned to those without IS for 28 days starting within one month of topiramate initiation. Results: All 39 patients identified received topiramate prior to the implementation of a standardized management protocol in September 2012. After this time, topiramate was no longer used. Six patients who started topiramate concurrently with first-line therapy (ACTH, oral corticosteroids, or vigabatrin) and one in whom remission could not be determined were excluded. Thirty-two topiramate monotherapy patients were analyzed. Topiramate was used as the initial treatment in 17 patients. Other patients received topiramate as the second (10), third (4) or fourth (1) treatment. We identified two patients with a clinical remission. These patients received topiramate as the second or fourth treatment. Although the EEG improved in one patient, he later experienced clinical and electrographic relapse. While the other patient’s EEG normalized with prior ACTH treatment, IS did not resolve until after starting topiramate. Conclusions: The rate of clinical remission with topiramate was 6% (2/32). Temporary electrographic improvement occurred in one of these patients. This study included a relatively large number of patients who received topiramate as the first or second treatment for IS. These findings suggest that topiramate is not an optimal therapy for IS