Ketogenic Diet and Epilepsy

Ketogenic Diet and Epilepsy SIR-Dr. Jeavons (DMCN, 17, 534) attempts to justify the omission of the ketogenic diet regimen in a recently published handbook on epilepsy’ by stating “It is possible that European authors do not nowadays mention ketogenic diet because better and easier therapy has been available for many years.” The administration of anticonvulsant medication is certainly easier than prescribing and maintaining the ketogenic diet regimen, but we completely disagree with Dr. Jeavons’s opinion that drug therapy is better than the ketogenic diet in the treatment of childhood myoclonic epilepsy, and we wholeheartedly support Dr. Berman’s statements on the subject (DMCN, 17, 255). In addition, we do not believe that ‘easier’ should be a pertinent consideration in the selection of therapy for so serious and so notoriously intractable a disorder as myoclonic epilepsy of childhood. We have had approximately 40 years experience with the use of the ketogenic diet regimen in the treatment of childhood myoclonic seizures and have consistently found it to be the most efficacious form of therapy for this type of ep i l ep~y~-~ . During this period we have studied and treated approximately 1500 children with myoclonic epilepsy: 1150 suffered with myoclonic epilepsy of infancy (West syndrome, infantile spasms, hypsarhythmia) and 350 with myoclonic epilepsy of older children (Lennox syndrome, Lennox-Gastaut syndrome, petit ma1 variant, modified hypsarhythmia). We prescribed the ketogenic diet regimen to 915 of these patients with the following results: seizures were controlled in 485 (53 per cent); there was marked improvement in 238 (26 per cent); and 192 (21 per cent) did not respond to this therapy. Anticonvulsant medication had been given adequate trial in 732 of these children and 183 had received no previous treatment. Dr. Jeavons also states “It is perhaps significant that the effective methods of therapy such as nitrazepam (clonazepam has only recently been approved) and sodium valproate have not been available in the United States.” We have had no experience with sodium valproate, but we prescribed and evaluated nitrazepam on an investigational basis for a period of seven years. We administered this drug to approximately 100 patients and obtained complete, lasting seizure control in only five cases. However, many of the patients in whom nitrazepam therapy was unrewarding were subsequently totally relieved of their seizures or vastly improved with the use of the ketogenic diet. It is noteworthy that nitrazepam was withdrawn from clinical investigation in the United States by the manufacturer, in favor of clonazepam. During the past 14 months, we have prescribed clonazepam to 11 patients with childhood myoclonic seizures by adding it to their previous anti-epileptic regimen, which consisted of maximal doses of standard anticonvulsant drugs in various combinations. Six of these children had reduced frequency of attacks, but the other five did not respond to clonazepam therapy. Our investigation was too brief to determine whether the anticonvulsant effect of clonazepam, like that of diazepam, diminishes with the passage of time; however, in a reappraisal of the treatment of epileptic seizures with clonazepam, Fazio et a/.6 reported “a consistent decrease in efficacy. . . after several months of treatment.” Three of the five patients who did not benefit from clonazepam (one with West syndrome and two with Lennox syndrome) were subsequently treated with the ketogenic diet regimen. Seizures have been controlled in one patient for nine months and in the other two children