Real-world utilization of Cenobamate as adjunct therapy in office-based neurology: practical tips and insights for titration.

Introduction: Epilepsy poses significant management challenges, particularly in patients with refractory epilepsy where conventional antiseizure medications (ASMs) are ineffective. Cenobamate (CNB), a recently approved third-generation ASM, has shown unprecedented efficacy as an adjunctive therapy in clinic-based practice. However, to date, its use by office-based neurologists in Germany remains relatively limited. One reason for this is its perceived complexity and false perception as a medication of last resort. This study focuses on the logistics of German care pathways, CNB titration, and ASM combinations in a first cohort of office-based outpatients. It also gives a glimpse into which ASMs are being used in the office-based setting in comparison to population and clinic-based data sources. Methods: The cohort comprised 55 patients from two office-based outpatient practices ( Results: Prior to CNB initiation, patients at both office-based practices had similar levels of 1-2 concurrent ASMs (Berlin 80%; Hamburg 77%). The most common ASMs were voltage-gated sodium channel blockers (VGSC), Levetiracetam (LEV)/Brivaracetam (BRV) synaptic vesicle protein 2A (SV2A) inhibitors, and Perampanel (PER). CNB titration was configured into a quarterly office-based outpatient schedule. All patients had seizure reductions in-line with published and real-world evidence, and were compliant. Discussion and conclusion: CNB is a valuable adjunctive therapy suitable for refractory epilepsy outpatients attending office-based neurologists. A slow titration schedule helped mitigate most side effects. Despite differences to clinic-based practice, in office-based outpatient practice CNB can be broadly used. It can be prescribed to patients on conventional therapy who are still having seizures and have failed two or more other ASMs. By reporting experiences of CNB titration, seizure, and drug load reduction outcomes in office-based neurology, this study will give German office-based outpatient neurologists evidence to support both CNB and other third-generation ASM use in their practice.