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.
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.
- 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
- 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