Epilepsy: from consensus to daily practice

Pharmacotherapy of epilepsy: new armamentarium, new issues

Since 1990 there have been over ten antiepileptic drugs (AEDs) approved for the therapy of epilepsy. These agents have a new spectrum of efficacy and novel adverse effects, some totally unexpected. They also represent an enormous escalation of costs. Few have been subjected to head-to-head comparisons in monotherapy against established AEDs. The aim of therapy is to eliminate rather than to reduce seizure manifestations. Many traditional agents have been phased out due to poor tolerability. New epilepsy syndromes and genetic contributions to epilepsy have been refined. Special considerations apply to various classes of sufferers such as the elderly, women of childbearing age, and sufferers with concomitant disorders, treated with medications capable of drug interactions. There is a recognition of the value of slow introduction, a preference for monotherapy, recognition of the effects of AEDs on hormones and reproductive function and effects on the fetus exposed to AEDs in utero, comprising physical malformations and effects on cognitive development. A balance between efficacy and safety is pivotal, as every preference about the initial pharmacotherapy of epilepsy and subsequent polytherapy has its protagonists. With improvement in diagnostic techniques and new therapeutic modalities it is likely that in the future, pharmacogenomics and an understanding of pharmacoresistance may influence drug selection for individual patients with epilepsy.

Opinion of Belgian neurologists on antiepileptic drugs: Belgian Study on Epilepsy Treatment (BESET)

OBJECTIVES

To describe the choice of treatment in adult patients with epilepsy in Belgium, to detect the presence or absence of consensus among neurologists in epilepsy treatment, and to analyze the gaps between current guidelines and prescriptions.

MATERIALS AND METHODS

Hundred Belgian neurologists were systematically interviewed between May and June 2003 using a structured questionnaire (modified Rand method).

RESULTS

Initial monotherapy was the preferred treatment strategy. Valproate was the first choice in idiopathic generalized epilepsy (IGE) and carbamazepine in focal epilepsy (FE). The new antiepileptic drugs (AED) were usually recommended in second-line. However, in special treatment situations, they were considered first-line, e.g., lamotrigine in case of women of childbearing age.

CONCLUSIONS

Neurologists reached consensus for most questions on epilepsy treatment. In 2003, monotherapy with valproate and carbamazepine was the common treatment strategy in Belgium, whereas lamotrigine and to a lesser extent levetiracetam, topiramate, and oxcarbazepine were predominantly prescribed in second-line. This is in agreement with the recently published UK epilepsy guidelines but not in agreement, however, with the US guidelines, that for new onset epilepsy, new and old drugs are equally effective. Belgian neurologists, except for some special situations still prefer old drugs as first line.