Strategies for Optimizing Antiepileptic Drug Therapy in Elderly People

Thomas E. Lackner, Pharm.D., FASCP


Pharmacotherapy. 2002;22(3) 

In This Article

Role of Newer AEDs

Given the physiologic changes of advancing age, comorbid illness, and polypharmacy in elderly people, newer AEDs may have theoretical advantages over older ones. Drug selection should be individualized, with consideration given to availability of the product formulation, efficacy, adverse drug reactions, drug-disease and drug-drug interactions, and cost. Although currently approved by the FDA only as adjunctive therapy for refractory partial seizures, newer AEDs have several qualities that make them especially attractive for elderly patients. They have fewer drug-drug interactions, a greater margin of safety, and may be better tolerated than traditional AEDs.[69,230,299] Furthermore, their dosages are not complicated by complex pharmacokinetics characterized by phenytoin and carbamazepine, and they do not require routine SDC monitoring, which further simplifies therapy and lowers cost. These features increase the likelihood of patient tolerance and compliance and the ability to escalate the dosage to achieve an optimum response. Whereas none of the newer AEDs has proved to be more effective than other AEDs (new or traditional) for partial seizures, their mechanisms of action may result in enhanced seizure control as adjunctive therapy, and perhaps monotherapy, in patients inadequately controlled with traditional agents.[12,13,14,15,68]

The higher direct cost of newer AEDs compared with traditional AEDs may be mitigated by decreased frequency of seizure-related complications, emergency care, and related medical costs, with improved compliance and quality of life, but this remains to be proved.[300,301] It is also important to remember that the cost of traditional AEDs constitutes less than 10% of the overall cost of managing epilepsy.[300,301] The costs of epilepsy care are reduced with improved seizure control.[300,301]

Therapy with AEDs for various nonseizure conditions continues to increase, and the role of newer AEDs in these conditions is promising.

Shortcomings of newer AEDs are lack of liquid and parenteral formulations (especially intramuscular) and compulsory slow dosage titration for lamotrigine and topiramate. Dosages of gabapentin and topiramate must be adjusted for renal impairment, but this may offer cost savings. Finally, to establish the role of the newer AEDs, there is clearly a need for additional clinical trials on the efficacy and safety of these agents as adjunctive therapy and monotherapy compared with traditional agents in elderly patients.