Practice Therapeutics

Newer drugs for focal epilepsy in adults

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e345 (Published 26 January 2012) Cite this as: BMJ 2012;344:e345
  1. Martin J Brodie, professor 1,
  2. Patrick Kwan, professor of neurology2, consultant neurologist3
  1. 1Epilepsy Unit, Western Infirmary, Glasgow G11 6NT, UK
  2. 2Departments of Medicine and Neurology, University of Melbourne, Royal Melbourne Hospital, Melbourne VIC 3050, Australia
  3. 3Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong
  1. Correspondence to: P Kwan patrick.kwan{at}unimelb.edu.au

A 28 year old woman sees her general practitioner after experiencing what sounds like a convulsion without any apparent provoking factor. Over the past month she has also had “blank spells” during which her husband noticed her to be unresponsive. Her general practitioner suspects she may have developed focal epilepsy and refers her to an epilepsy specialist. The specialist elicits from the patient and her husband additional features in the history that are highly compatible with seizures arising from the temporal lobe (lip smacking, ipsilateral motor automatism, and contralateral dystonia) and confirms the diagnosis by finding focal epileptiform discharges on electroencephalography and cortical dysplasia in the left temporal lobe on brain imaging. To prevent further seizures the specialist advises treatment with antiepileptic drugs (AEDs). The patient is reluctant to start treatment because she has read that AEDs have many adverse effects, could interact with her oral contraception, and are harmful for babies. She wonders if there are newer AEDs that for her might be better than the traditional ones.

What are the newer antiepileptic drugs?

Epilepsy is resistant to drug treatment in a third of patients.1 Driven by this high prevalence of drug resistance, 12 agents have been developed to treat adult epilepsy since the late 1980s. These are often referred to collectively as the “newer” antiepileptic drugs—that is, newer than the established drugs, such as phenobarbital, phenytoin, carbamazepine, sodium valproate, and several benzodiazepines, with phenobarbital having been around for 100 years.2 In this article we will review the clinical use of (in chronological order of approval in the United Kingdom) lamotrigine, gabapentin, topiramate, oxcarbazepine, levetiracetam, pregabalin, zonisamide, and lacosamide (table 1). We will not discuss the other newer AEDs tiagabine and vigabatrin because they are rarely used for focal epilepsy in adults (owing to efficacy and safety concerns respectively) or eslicarbazepine acetate …

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