Dietary Approaches to Non-Lesional Epilepsy

December 8, 2013

Eric H. Kossoff, MD Johns Hopkins University

Baltimore, Maryland

American Epilepsy Society | Annual Meeting

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Disclosures

Nutricia, Inc.

Atkins Nutritionals, Inc., NeuroPace, Inc.

American Epilepsy Society | 2013 Annual Meeting

Grant Support

Scientific Advisory Boards

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Learning Objectives

• Recognize the different ketogenic diets available today for children and adults with epilepsy.

• Realize how different dietary therapies today are compared to several decades ago.

• Understand the true benefits (and risks) of these therapies for patients with non-lesional epilepsy.

American Epilepsy Society | 2013 Annual Meeting 3

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1921-2000: The “Classic” Ketogenic Diet

• Tried for all children, including lesional cases

• Started in the hospital gradually over 4-5 days after a fast

• Fluid and calorie-restricted

• Foods weighed on gram scales precisely

• Intensive dietitian involvement

• Minimum 6 months, maximum 2 years

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Ketogenic Diet Studies Published

0

20

40

60

80

100

120

140

160

180

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Masino & Rho 2012

Henderson J Child Neurol 2006 8

Subject

entry

Randomize

Screening

visit

Randomized Controlled Study MCT keto diet

Classical keto diet

4 weeks Controls

12 weeks

Diet 12months

Neal, et al. Lancet Neurol 2008

Slide courtesy of Dr. Helen Cross

6-Month Seizure Reduction from Ketogenic Diet

<50%

Seizure-free

90-99%

50-90%

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Kossoff et al., Epilepsia 2005 (updated 2013) 15

2013: A Gentler and Smarter Ketogenic Diet

• We know who does best

• Fasting and admission not required

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Kossoff Epilepsia 2009 17

Surgery vs. Diet

• 45 children with lesional epilepsy – 24 underwent surgery

• Surgery: 63% seizure-free • KD: 0% seizure-free

• In general, the KD is used

primarily in patients with generalized, non-lesional epilepsy

Stainman R, et.al. Seizure 2007 18

Do we need to Fast?

• Good evidence of identical 3-month equivalency – Wirrell 2002 – Kim 2004 – Vaisleib 2004 – Bergqvist 2005

Bergqvist AG, et.al. Epilepsia 2005

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Kossoff Epilepsia 2008 20

2013: A Gentler and Smarter Ketogenic Diet

• We know who does best

• Fasting and admission not required

• Adjust calories, ratio, fluids for growth and satiety NOT for seizure control

• www.ketocalculator.com

• Adverse effects prevented…not just treated

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Potential Side Effects

• Constipation • Weight loss • Vomiting • Acidosis

• Kidney stones • Growth slowing • Hyperlipidemia • Vitamin D deficiency

• Prolonged QT (selenium deficiency related)

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Kossoff Epilepsia 2009 23

Kidney Stones and Oral Citrates

• Kidney stones occur in 6% historically

• NOT higher in those on topiramate or zonisamide

• Cytra-K (30 meq twice daily)

• Reduces risk of kidney stones on the KD from 6-fold when used empirically

McNally et al. Pediatrics 2009 24

2013: A Gentler and Smarter Ketogenic Diet

• We know who does best

• Fasting and admission not required

• Adjust calories, ratio, fluids for growth and satiety NOT for seizure control

• www.ketocalculator.com

• Adverse effects prevented…not just treated

• Minimum and maximum durations have changed

• 3 other diets available: – MCT diet

– Modified Atkins Diet

– Low glycemic index treatment

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How Long is Enough?

• Most studies show benefit within 2-4 weeks – We suggest 3 months minimum

• Traditional duration is 2 years – For infantile spasms, shorter durations have been

reported

• Children/adults can remain on dietary therapy 20-30 years if necessary

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• No calorie or fluid restriction

• No hospital admission (clinic education)

• No weighing of foods on gram scales

• No fasting required

The Modified Atkins Diet

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“MAD”: Other Potential Advantages

• Less time needed for parent education

• Can be started urgently in the clinic

• Parents can do it along with their child

• Products available in stores

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MAD at a Decade

• 32 publications from 2003-2013 – 17 prospective studies in children and adults

• 208 (48%) of 434 patients with >50% seizure

reduction to date – 55 (13%) became seizure-free

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Low Glycemic Index Treatment

• Target carbohydrates with glycemic indicies <50

• Similar composition to the MAD

• Does not induce urinary ketosis

• Reported recently as beneficial for tuberous sclerosis and Angelman syndrome

30 Muzykewicz et al. Epilepsia 2009

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Diets for Adults

• Centers in Baltimore, Chicago, London, India, Washington (so far)

• Modified Atkins Diet probably the most straightforward to use

• Consider ketogenic diet for adults with gastrostomy tubes or in status epilepticus

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Impact on Clinical Care and Practice

• Using diets can be very helpful, especially for patients with non-lesional epilepsy

• Consider earlier in the management of refractory epilepsy

• Safer and easier to use than decades ago

• Also of potential value for adults, especially with non-lesional epilepsy

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