Practical consensus recommendations for polytherapy involving stiripentol in Dravet syndrome: A nominal group approach.

objectivesDravet syndrome (DS) is a drug-resistant developmental and epileptic encephalopathy, often requiring three or more antiseizure medications (ASMs). Consequently, the therapeutic landscape is highly complex, combining DS-specific agents (stiripentol, STP; cannabidiol, CBD; fenfluramine, FFA), non-specific ASMs, and non-pharmacologic options such as dietary therapy or neuromodulation. In addition, recognition of patients' changing needs across the lifespan, together with the essential contribution of caregiver education to effective treatment oversight-including awareness of potential drug-drug interactions and adverse events-emphasizes the value of an integrated and forward-looking approach. A consensus initiative was developed to guide clinicians in the management of patients with DS, with a particular focus on STP-containing regimens.

methodsBased on a literature review and clinical vignette discussions, a nominal group of five international DS experts developed 38 statements across six themes: (i) general principles, (ii) guiding physicians to empower families, (iii) STP as add-on to specific and non-specific Dravet ASMs, (iv) FFA in regimens containing STP, (v) CBD in regimens containing STP, and (vi) patient follow-up during treatment initiation. Statements were scored on a 9-point Likert scale (1 = strongly disagree, 9 = strongly agree) first by the nominal group and then by an international panel of 59 DS clinicians. Consensus was defined as ≥75% rating ≥7 and/or a median ≥8.

resultsThirty-four of the 38 statements (89%) reached consensus among both the nominal group and the international panel; one did not reach consensus in either, and three reached consensus only among the nominal group. Both panels agreed on the importance of involving families in treatment decisions and follow-up, as well as on key aspects of polytherapy management, including ASM initiation, treatment adjustments, and adverse event management. SIGNIFICANCE: This international consensus integrates evidence and clinical expertise to establish shared principles that address a long-standing gap in the polytherapeutic management of Dravet syndrome. PLAIN LANGUAGE SUMMARY: Dravet syndrome is a rare and severe form of epilepsy that begins in early childhood, with seizures that often persist throughout life. Because the disease is highly drug resistant, most patients are treated with polytherapy, making clinical management complex for clinicians. This consensus brings together published evidence and expert experience to provide practical guidance on the management of polytherapy in Dravet syndrome, supporting clinicians in optimizing patient care.