Drug selection for the newly diagnosed patient: When is a new generation antiepileptic drug indicated?

Abstract

Treatment options in epilepsy have increased dramatically since the early 1990s with the introduction of nine new generation antiepileptic drugs (AEDs) (felbamate, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, tiagabine, topiramate, vigabatrin and zonisamide). This makes drug selection much more complicated and challenging. This review discusses drug selection in patients with newly diagnosed epilepsy and in particular the role of new AEDs in this population. The choice of treatment should always be based on a careful comparison of the risk-benefit ratio for the different treatment options and the outcome of such evaluation may be different in patients with new onset compared with chronic epilepsy. Efficacy, tolerability and safety are the main criteria for selection of AEDs and any first line drug for patients with newly diagnosed epilepsy must have demonstrated satisfactory efficacy as monotherapy in that patient population. So far, of the new AEDs only lamotrigine, oxcarbazepine and topiramate have documentation sufficient to be granted licence for use as monotherapy in most European countries. Because the new generation AEDs have failed to demonstrate improved effectiveness as monotherapy, old generation AEDs such as carbamazepine and valproate remain drugs of first choice for partial and generalised seizures, respectively. However, there are special situations and populations where a new AED may be a reasonable first line drug. These include vigabatrin in West syndrome associated with tuberous sclerosis, lamotrigine as alternative to valproate in idiopathic generalised seizures in women of childbearing potential and lamotrigine for the treatment of epilepsy in the elderly population. The role of the new generation AEDs is likely to become more prominent as more experience is gained.

An International Multicenter Randomized Double‐Blind Controlled Trial of Lamotrigine and Sustained‐Release Carbamazepine in the Treatment of Newly Diagnosed Epilepsy in the Elderly

“…Although phenytoin and, to a lesser extent, valproic acid and phenobarbital are still widely prescribed for the management of epilepsy with onset in old age (Pugh et al, 2004;Perucca et al, 2006), many physicians consider CBZ as a preferable old generation AED in this population (Tallis et al, 2002), a practice supported by a Cochrane metanalysis in which a trend for CBZ to be superior to valproic acid against partial seizures became more evident with increasing age (Marson et al, 2002). In the last 15 years, the advent of new generation AEDs has provided attractive options for the management of seizure disorders in the elderly because some of these drugs have a favorable tolerability profile and a lower potential to interact with other drugs and aggravate comorbidities (Willmore, 2000;Alvarez-Sabin et al, 2002;Tomson, 2004;Karceski et al, 2005). Among newer AEDs, LTG has been the most extensively investigated in older patients, and is often regarded as the treatment of choice for the majority of such patients (Willmore, 2000;Karceski et al, 2005).…”

Teratogenicity of the newer antiepileptic drugs – the Australian experience

“…Their favorable pharmacokinetic profiles may render them suitable for use in polytherapy and in special situations such as in pregnant women with epilepsy (WWE). [1][2][3] However, there are also the important issues of the possible teratogenic effects of these newer AED when taken in pregnancy, how they compare with the older generation of AED in this regard, and whether such effects may extend to both the physical and the cognitive development of the infant.…”

A 3 year audit of adult epilepsy care in a Nigerian tertiary hospital (2011-2013)

“…[3,13,14] Although, 17% of patients were documented not to have complied with prescribed drug, this proportion was likely to be an understatement. As out-of-pocket expenditure was the major payment method for health care services in the country, [21] and 46% of patients were unemployed, and 53% depended on someone to pay their health bill. Other constraints that could have limited epilepsy care were the lack of necessary equipment to measure serum level of AEDs and video EEG.…”