April 27, 2004

Melissa Schorr

April 27, 2004 (San Francisco) — Physicians who prescribe medication for epileptic patients must take into account which drugs will be most suited to patients' particular needs, considering medical history, age, sex, potential long-term adverse effects, and the benefits of newer drugs, according to new guidelines issued here by the American Academy of Neurology (AAN) and the American Epilepsy Society at the AAN annual meeting.

"There has been an explosion in the number of epilepsy drugs, which is a lot for physicians to come to terms with," said Jacqueline French, MD, a professor in the department of neurology at the University of Pennsylvania in Philadelphia. "We wanted to explain the advantages and disadvantages of the new drugs and where physicians should use them."

The new guidelines, which are published in the April 27 issue of Neurology, offer physicians guidance on seven new antiepileptic medications released in the past 10 to 15 years, divided into recommendations for newly diagnosed and refractory patients.

The guidelines include specific advice for patients with refractory epilepsy, which makes up 30% to 40% of all patients with epilepsy. Physicians treating adult patients with partial epilepsy were advised to consider topiramate, oxcarbazepine, or lamotrigine as monotherapy, Dr. French said.

A major problem for unresponsive patients has been the lag time in aggressively receiving treatment of medications or progressing to surgery, said Jerome Engel, Jr., MD, a professor of neurology and chief of epilepsy at the University of California in Los Angeles. "If you can stop the seizures early, you can rescue patients from a lifetime of disability."

For patients with newly diagnosed epilepsy, physicians should consider trying newer antiepileptic drugs from the outset, despite the higher cost, because once a drug is prescribed, a patient is often highly reluctant to switch, despite known adverse effects of many of the older antiepileptic medications. Some of the older antiepileptic drugs, which include phenobarbital and primidone, have been found to elevate homocysteine levels, increase the risk of osteoporosis, and interfere with the metabolism of other drugs, such as birth control pills, Dr. Engel said.

"These drugs have long-term effects," he said. "It's better not to be on them an entire lifetime if you don't have to be."

For newly diagnosed adults and adolescents with partial or mixed seizure disorders, the guidelines suggest oxcarbazepine, which is approved by the U.S. Food and Drug Administration for monotherapy, as well as gabapentin, lamotrigine, and topiramate, which are approved in the United States for adjunctive therapy but have been studied in Europe.

"The choice of an initial drug is extremely important, so you have to make the proper choices," said Dr. French. "There are advantages of the new drugs."

The newer antiepileptic drugs are better tolerated, have less effect on homeostasis, and there is a lower rating for the risk of birth defects, she noted.

Physicians also need to take into consideration the needs of specific subgroups when prescribing, Dr. French added.

For example, most old antiepileptic drugs, as well as topiramate and oxcarbazepine, have been found to interfere with the effectiveness of oral contraceptives for women, putting them at increased risk of unintended pregnancies.

For newly diagnosed children with absence seizures, gabapentin and lamotrigine were recommended for having less of an effect on neuropsychosocial measures, said Andres Kanner, MD, professor of neurological sciences at Rush University Medical Center in Chicago, Illinois.

Eric Hargis, president of the Epilepsy Foundation, a patient advocacy group, pointed out that health insurance providers and formularies must offer coverage of all the new drugs,despite the higher short-term cost. "Epilepsy isn't a cookie-cutter disease, there is no best epilepsy medicine. Physicians must have access to all drug options," he said.

"Cost savings by restricting access is often illusory in epilepsy," Dr. Hargis added. "If a patient has a seizure on the wrong medication, it can cost thousands of dollars in hospital costs and visits to the emergency room."

AAN 56th Annual Meeting: Special Media Briefing. Presented April 27, 2004.

Reviewed by Gary D. Vogin, MD

Melissa Schorr is a freelance writer for Medscape.

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