August 21, 2018
New recommended practice guidelines for the management of new-onset and treatment-resistant epilepsy with anti-epileptic drugs (AEDs) have been released by the American Academy of Neurology (AAN) and American Epilepsy Society (AES).
The AAN and AES formed an expert subcommittee of members from both organizations who updated the 2004 evidence-based guidelines on epilepsy treatment with AEDs. According to the committee’s findings, the new guidelines highlight evidence supporting the use of lamotrigine, vigabatrin, levetiracetam, pregabalin, gabapentin, and zonisamide for reducing the frequency of seizures in new-onset focal epilepsy and treatment-resistant epilepsy.
Based on evidence reviewed by the committee, AAN and AES recommend the use of gabapentin and topiramate in adults and children with newly diagnosed epilepsy. Additional Class I and II studies support the use of rufinamide, ezogabine, clobazam, perampanel, and immediate-release pregabalin as add-on therapy in adults with treatment-resistant focal epilepsy. However, the agency notes that there are adverse events associated with these treatments that should warrant careful consideration when prescribing. Further Class I, II, and III studies suggest eslicarbazepine at 800 mg/day and 1200 mg/day may possibly be effective in treatment-resistant adult epilepsy.
Lamotrigine should be considered over gabapentin or immediate-release carbamazepine due to better tolerability for monotherapy in adults with new-onset epilepsy with either focal epilepsy or unclassified tonic-clonic seizures, according to the subcommittee. Additionally, there is no difference between controlled-release carbamazepine and levetiracetam or zonisamide for reducing seizure frequency in patients with focal epilepsy or unclassified tonic-colonic seizures.
Further recommendations include lamotrigine over pregabalin in reducing secondarily generalized tonic-clonic seizures within a 6-month period. According to Class II evidence, eslicarbazepine may be more effective than monotherapy for reducing seizure frequency in adults with treatment resistant focal epilepsy.
Despite updated recommendations, the authors of the guidelines suggest the need for future studies in order to develop more definitive treatment recommendation.
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