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Tailoring Treatment for Epilepsy

The landscape of epilepsy treatment has changed dramatically over the last 15 years, with seven new drugs hitting the market since 1990. To ensure that people living with epilepsy receive the medication that best meets their needs, treatment guidelines were recently released by the American Academy of Neurology and the American Epilepsy Society.

"Because so many drugs were approved in such a short period of time, there was an enormous amount of confusion." said Jacqueline French, MD, a professor of neurology and co-director of the University of Pennsylvania Epilepsy Center in Philadelphia. "Our primary motivation was to teach physicians about each of these drugs."

The 24-member committee reviewed the evidence on the effectiveness, tolerability and safety of the seven new anti-epileptic drugs and published their recommendations in the April 27 issue of Neurology. The guidelines offer recommendations for people with partial seizure disorders, in which abnormal activity takes place in one part of the brain, and generalized seizure disorders, which affect many parts of the brain.

Separate guidelines were created for newly diagnosed patients and for those with epilepsy that has not responded to treatment. For newly diagnosed patients with either partial or mixed seizure disorders, the authors recommend four drugs—gabapentin (Neurontin), lamotrigine (Lamictal), topiramate (Topamax) and oxcarbazepine (Trileptal)—as single-drug therapy, otherwise known as monotherapy. Epilepsy drugs can be given alone or in combination. Most physicians and patients prefer monotherapy because it is an easier regimen to follow and usually has fewer side effects.

Only oxcarbazepine has been approved as monotherapy by the Food and Drug Administration for people with newly diagnosed epilepsy. According to Dr. French, the authors of the guidelines believe that European studies have established that the other three drugs are as effective as older anti-epileptic medications, and are better tolerated by patients.

For people with treatment-resistant epilepsy, the guidelines state that the medication choice should be tailored to the patient based, in part, on the type of seizure disorder they have. For example, they recommend oxcarbazepine, topiramate, or lamotrigine as monotherapy in adults with partial epilepsy. And they advise that gabapentin, lamotrigine, oxcarbazepine and topiramate are effective for children with partial seizures.

When selecting a medication, other factors that physicians should consider are age, the presence of other health conditions, and the other medications someone may be taking. For example, certain medications may increase risk of osteoporosis. And many older medications may decrease the effectiveness of birth control pills.

"The guidelines were developed to remind people that there is significant choice available to them and to show to what extent people have had their seizures improved by having these drugs added to their regimen." Dr. French said. "Doctors do tend to get into patterns where they use one drug for everyone, but they need to fit the drugs to the patient."