Treatment of New-Onset Epilepsy: AAN, AES Update Practice Guidelines

girl with EEG cables for test
girl with EEG cables for test
An expert subcommittee was formed consisting of members of the AAN and AES to update the 2004 evidence-based guidelines on epilepsy treatment with AEDs.

The American Academy of Neurology (AAN) and the American Epilepsy Society (AES) have provided new recommended practice guidelines for the management of new-onset and treatment-resistant epilepsy with anti-epileptic drugs (AEDs).1,2 The new guidelines highlight the 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.

An expert subcommittee was formed consisting of members of the AAN and AES to update the 2004 evidence-based guidelines on epilepsy treatment with AEDs. Based on recent evidence, the investigators recommend the use of gabapentin and topiramate in adults and children with newly diagnosed epilepsy.

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 adverse events associated with these therapies warrant careful consideration prior to prescribing. Other studies (class I, II, and III) suggest eslicarbazepine at 800 mg/day and 1200 mg/day may possibly be effective in treatment-resistant adult epilepsy.

For monotherapy recommendations in adults with new-onset epilepsy with either focal epilepsy or unclassified tonic-clonic seizures, lamotrigine should be considered over gabapentin or immediate-release carbamazepine due to better tolerability, according to class II evidence.

In addition, class II evidence appears to demonstrate no difference between controlled-release carbamazepine and levetiracetam or zonisamide in terms of reducing seizure frequency in patients with focal epilepsy or unclassified tonic-colonic seizures.

Lamotrigine is recommended over pregabalin in reducing secondarily generalized tonic-clonic seizures within a 6-month period. In adults with treatment-resistant focal epilepsy, class II evidence points to eslicarbazepine as a possibly effective monotherapy for reducing seizure frequency. Comparatively, levetiracetam, oxcarbazepine, and zonisamide may be an effective add-on therapy in pediatric patients with treatment-resistant focal epilepsy.

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According to the guideline authors, there is a need for future studies which “use doses commonly used in clinical practice and use flexible-dosing regimens” in order to develop more definitive treatment recommendations.

References

  1. Kanner AM, Ashman E, Gloss D, et al. Practice guideline update summary: Efficacy and tolerability of the new antiepileptic drugs I: Treatment of new-onset epilepsy: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Epilepsy Society [published online June 13, 2018]. Neurology. doi:10.1212/WNL.0000000000005755
  2. Kanner AM, Ashman E, Gloss D, et al. Practice guideline update summary: Efficacy and tolerability of the new antiepileptic drugs II: Treatment-resistant epilepsy: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Epilepsy Society [published online June 13, 2018]. Neurology. doi:10.1212/WNL.0000000000005756