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Treatment-Refractory Epilepsy: An Evidence-Based Approach to Antiepileptic Monotherapy

Published online by Cambridge University Press:  07 November 2014

Cynthia L. Harden ,
David L. Ginsberg ,
Andres M. Kanner ,
Jocelyn F. Bautista  and
Thomas R. Browne
Cynthia L. Harden
Affiliation:
Dr. Harden is associate professor of neurology and neuroscience at the Comprehensive Epilepsy Center at, Weill College of Cornell Universityin New York City
Andres M. Kanner
Affiliation:
Dr. Kanner is professor of neurological sciences at Rush Medical College, director of the Laboratory of Electroencephalography and Video-EEG-Telemetry, and associate director of the Section of Epilepsy and Clinical Neurophysiology and Rush Epilepsy Center at, Rush University Medical Center in Chicago, Illinois
Jocelyn F. Bautista
Affiliation:
Dr. Bautista is associate staff physician in the Department of Neurology, Section of Epilepsy and Sleep Disorders, at the Cleveland Clinic Foundation in Ohio
Thomas R. Browne
Affiliation:
Dr. Browne is professor of neurology at, the Boston University School of Medicine, and director of the Boston Medical Center Comprehensive Epilepsy Program, both in Massachusetts
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Abstract

Treatment options for epilepsy have increased in the last decade with the introduction of several new antiepileptic drugs (AEDs). As drug selection becomes more challenging, the use of evidence-based guidelines to aid in treatment decisions has become increasingly valued. The American Academy of Neurology's (AAN) guidelines for the use of new AEDs in refractory epilepsy offers many benefits, including expert panel recommendations based on clinically relevant questions with evidence-based responses. However, lack of evidence from randomized-controlled trials, particularly as they relate to monotherapy, limits the recommendations and their use in practice. The studies of new AEDs as monotherapy in treatment-refractory epilepsy are difficult to incorporate into clinical use because they are driven by Food and Drug Administration requirements to show superiority over placebo or pseudoplacebo (ie, low dose of active drug) rather than by clinical questions. However, based on Class I evidence, the AAN guidelines have granted Level A recommendations (established effectiveness) for oxcarbazepine and topiramate monotherapy, and a Level B recommendation (probable effectiveness) for lamotrigine monotherapy in the use of refractory partial epilepsy. There is insufficient evidence to recommend gabapentin, levetiracetam, tiagabine, or zonisamide monotherapy. No monotherapy AED trials have been conducted in refractory generalized epilepsy. Because no differences in efficacy have been reported for AEDs as initial therapy of partial seizures, differences in adverse events, such as weight gain, tremor, and hair loss, are key in drug selection. More comparative studies between the AEDs are necessary for both monotherapy and add-on therapy for treatment-refractory epilepsy.

Type
Research Article
Information
CNS Spectrums , Volume 10 , Issue S3 , 2005 , pp. 1 - 16
Copyright
Copyright © Cambridge University Press 2005

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