COMMENTARY

Which Antiepileptic Drugs Work Best?

Andrew N. Wilner, MD

Disclosures

October 17, 2011

In This Article

Which Antiepileptic Drugs Are Best for Seizures?

A wide range of antiepileptic drugs (AEDs) is available for the treatment of epilepsy (Table). Since 1993, the US Food and Drug Administration (FDA) has approved 13 new AEDs, with more in the pipeline. As the number of therapeutic options has increased, choosing the best AED for a particular patient has become more challenging.

Table. Currently Available Antiepileptic Drugs

Old Drugs (since 1912) New Drugs (since 1993)
Carbamazepine (Tegretol®) Ezogabine (Potiga®)
Divalproex sodium (Depakote®) Felbamate (Felbatol®)
Ethosuximide (Zarontin®) Gabapentin (Neurontin®)
Phenobarbital (Luminal®) Lacosamide (Vimpat®)
Phenytoin (Dilantin®) Lamotrigine (Lamictal®)
Primidone (Mysoline®) Levetiracetam (Keppra®)
Valproic acid (Depakene®) Oxcarbazepine (Trileptal®)
  Pregabalin (Lyrica®)
  Rufinamide (Banzel®)
  Tiagabine (Gabitril®)
  Topiramate (Topamax®)
  Vigabatrin (Sabril®)
  Zonisamide (Zonegran®)


With the exception of rufinamide, which is indicated uniquely for seizures associated with Lennox Gastaut syndrome, all of the new drugs are approved for the treatment of partial seizures.

Choosing an Antiepileptic Drug

Many factors must be considered when prescribing an AED for a particular patient including the patient's seizure type, epilepsy syndrome, history of allergies, medical and psychiatric comorbidities, potential drug-drug interactions, renal function, hepatic function, protein binding, possibility of pregnancy, dosing schedule, availability of liquid, parenteral and extended release formulations, pharmacogenetics, and cost. When AEDs are similar in efficacy, differences in tolerability often guide medication selection.

The growing science of pharmacogenetics has not yet provided new tools to predict drug efficacy in an individual patient.[1] However, pharmacogenetics does enable identification of Asian patients more likely to suffer carbamazepine-induced Stevens-Johnson syndrome and toxic epidermal necrolysis.[2] These adverse reactions may be avoided by prospectively testing patients for the human leukocyte antigen-B*1502 allele.

Overall, only about 50% of patients with newly diagnosed seizures become seizure free with their first AED.[3] This sobering statistic emphasizes the importance of trying the drug most likely to succeed the first time around to prevent further seizures and their related medical and psychosocial morbidity.

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