Published: Nov 1, 2013 | Updated: Nov 1, 2013

AUSTIN, Texas — One out of five seizure patients who did not initially respond to the high-fat, low-carb diet usually prescribed saw seizures cut in half after one or more of a handful of medication and dietary adjustments, researchers reported here.

Minor adjustments provided slight improvement in 42.2% of patients, more than 50% improvement in 17.8% of patients, and more than 90% improvement in 7.5% of patients who did not initially respond to the ketogenic diet usually prescribed to control epileptic seizures, according to Eric Kossoff, MD, of Johns Hopkins Children’s Center, and colleagues.

Total freedom from seizures was found among 3.3% of patients.

Adjustments in medication appeared to be more successful at managing seizures than adjustments to the ketogenic diet (24% versus 15%, P=0.08), the researchers reported at the Child Neurology Society annual meeting.

Using the high fat, low-carbohydrate diet to manage refractory epilepsy works in roughly 50% of cases, Kossoff said. Kossoff and colleagues presented evidence that fine-tuning adjustments to the diet and/or medications in the other 50% of cases might improve seizure managment and even provide freedom from seizures in a rare few.

Kossoff and colleagues looked at children on a ketogenic diet at Johns Hopkins Hospital from 2007 to 2013 that were still having seizures. They identified 10 dietary and supplement adjustments used to “fine-tune” the diet for better seizure management.

Interventions included:

• Adding the amino acid carnitine
• Increasing or decreasing calories
• Adding Medium Chain Triglycerides (MCT) oil
• Making changes in meal spacing
• Using one-time or intermittent fasting
• Eliminating artificial sweeteners
• Adding, or making adjustments to, medication

Out of the 200 children, 78% underwent at least one adjustment. Among 391 total interventions, 265 were performed specifically to control seizures. In some cases, more than one adjustment was implemented at a time. No more than four interventions were made in each case.

The average age at seizure onset was 1.6 years (range 0-14), and the average age at ketogenic diet initiation was 4.3 years ( Range .04-21). On average, patients were on 4.3 anticonvulsants (range 0-13). At the time of ketogenic diet initiation, an average of 2.2 anticonvulsants were being used by each patient (range 0-6).

Each additional fine-tuning measure did not increase the likelihood of achieving successful seizure management (P=0.44). The researchers regarded a more than 50% decrease in seizures as a success.

None of the interventions stood out as more successful than others at reaching seizure control (P=0.06). But calorie adjustments appeared to be the least helpful intervention (P=0.32).

Seizure improvement was more likely in younger patients (3.6 versus 5.1 years, P=0.02), patients that had seizure onset at a younger age (1.2 versus 2 years, P=0.049), and in patients with a lower seizure frequency at baseline (230 versus 527 seizures per month, P=0.003).

“These findings suggest that fine-tuning the ketogenic diet is helpful in approximately 1 in 5 patients, even after 14 months of use,” Kossoff and colleagues concluded.

Furthermore, they recommended that, if the ketogenic diet hasn’t been working, to try both medication and dietary adjustments.

In a talk at the Child Neurology Society annual meeting on refractory epilepsy, Nicolas S. Abend, MD, of the University of Pennsylvania in Philadelphia, said, “When anticonvulsants aren’t working for general epilepsy management and more and more refractory status, we think about the ketogenic diet.”

“We need to exclude certain metabolic conditions that are contraindications to the diet, and clearly implementation requires a multi-disciplinary team in the complex ICU [intensive care unit] environment in order to make sure infusions and other medications aren’t inadvertently administering glucose. But there are a number of case series in children and adults that suggests benefit from the ketogenic diet in these patients.”

Mohamad Mikati, MD, of Duke University, provided a possible explanation for the mechanisms of the ketogenic diet in elevating seizure activity in patients with the severe seizure condition of status epilepticus. Mikati posed that the ketogenic diet creates a therapeutic target by interfering with the programmed cell death involved with status epilepticus.