1. Home>
2. Specialties>
3. Neurology>
4. Clinical Practice Guideline Watch

Practice Parameters: Evaluation of the Newer Antiepileptic Drugs

These comprehensive guidelines can help guide decisions on when to prescribe each of seven newer AEDs.

A panel assembled by the American Academy of Neurology compiled these two practice parameters as clinical practice guidelines on the use of seven of the eight antiepileptic drugs approved for use in the U.S. between 1993 and 2000: gabapentin, lamotrigine, topiramate, tiagabine, oxcarbazepine, levetiracetam, and zonisamide. (The eighth, felbamate, was reviewed previously because of idiosyncratic systemic reactions not shared by the others; Epilepsia 1999; 40:803.) The panel systematically reviewed studies relevant to newly diagnosed and to medically refractory epilepsy, focusing on controlled clinical trials.

For newly diagnosed epilepsy, the panel concluded that gabapentin, lamotrigine, oxcarbazepine, and topiramate are effective as monotherapy. For absence seizures, they deem lamotrigine probably effective and gabapentin ineffective. They recommend that the choice between these seven drugs and the older drugs be guided by specific patient characteristics, noting that the older medicines tend to cost significantly less and are more familiar to practitioners than the new drugs, but also have more complex pharmacokinetics and drug interactions and, often, more adverse effects.

For adults with refractory partial epilepsy, the reviewers consider all of the drugs reviewed effective as adjunctive therapy, but only lamotrigine, topiramate, and oxcarbazepine effective as monotherapy. For the treatment of refractory tonic-clonic seizures in idiopathic generalized epilepsy, evidence supports using topiramate, and for symptomatic generalized epilepsy (mainly in children with Lennox-Gastaut syndrome), lamotrigine or topiramate. Evidence also supports the use of gabapentin, lamotrigine, topiramate, and oxcarbazepine as adjunctive therapy for refractory partial seizures in children.

Comment: This panel succeeded in extensively reviewing the literature on the new antiepileptic drugs and in publicizing appropriate off-label uses, such as gabapentin, lamotrigine, and topiramate for newly diagnosed epilepsy. A minor quibble is that the authors don't distinguish between drugs for which there is good evidence against effectiveness, such as gabapentin for absence seizures, and those for which there is insufficiently rigorous evidence in favor of use, such as topiramate, levetiracetam, and zonisamide for absence or myoclonic seizures. The main limitation of this review, however, as acknowledged by the panel, lies in the paucity of well-controlled, comparative trials, a problem that these guidelines should provide further incentive to resolve.

— Edward B. Bromfield, MD

Dr. Bromfield is Chief, Division of Epilepsy and EEG, Brigham and Women's Hospital, Boston.

Published in Journal Watch Neurology August 6, 2004

Citation(s):

French JA et al. Efficacy and tolerability of the new antiepileptic drugs I: Treatment of new onset epilepsy: Report of the Therapeutics and Technology Assessment Subcommittee and Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2004 Apr 27; 62:1252-60.

• Original article (Subscription may be required)
• Medline abstract (Free)

French JA et al. Efficacy and tolerability of the new antiepileptic drugs II: Treatment of refractory epilepsy: Report of the Therapeutics and Technology Assessment Subcommittee and Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2004 Apr 27; 62:1261-73.

• Original article (Subscription may be required)
• Medline abstract (Free)