Introduction—Annual Course 2008: American Epilepsy Society

Abstract

Innovations in care for patients with epilepsy evolve rapidly. Therefore, it is impossible for the busy clinician to keep abreast of all the new treatments and their place in the arsenal for treating epilepsy without receiving periodic comprehensive updates. The American Epilepsy Society Annual Course and this supplement are designed to provide clinicians who treat patients with epilepsy with the newest information, and to inform them about important controversies concerning the management of seizures and epilepsy syndromes. The articles in this supplement focus on the numerous new therapies now available, including medications, diets, surgical procedures, and stimulators. Our aim is to provide the newest information so that clinicians will be able to choose logically the best therapy available for each patient with epilepsy. Because there are so many new treatments now available, the average neurologist may be unaware of many of the latest therapies. Our intention is to attempt to close this gap between common therapeutic practice and knowledge of the newest therapies. How will closing the gap result in improvement in health outcomes of patients? After reading this supplement, physicians should be able to treat their patients based on the most recent evidence and treatment parameters, and should be aware of the evidence and controversies surrounding these treatments. These treatments will hopefully improve seizure control with minimal side effects, thereby improving the quality of life of the patient. The first article in this supplement is by Alexis Arzimangolu on the topic of Dravet syndrome. There is a new treatment available for this disorder, and it is, therefore, important to recognize this rather unusual syndrome. Although the syndrome is best known in infants, it continues throughout life; particularly for many adult patients who live with this syndrome, the neurologist, the patient, and the patient’s family may be unaware of the syndrome or of optimal treatment. Benign epilepsy of childhood with rolandic spikes is a condition for which the decision to treat is not obvious. W. Donald Shields and O. Carter Snead discuss the pros and cons of treatment, as well as which drugs might be useful if the decision to treat is made, in their discussion that focuses on the question “To treat or not to treat (and if to treat, with what)?” Another major problem faced by physicians is to determine the drug of choice for women with juvenile myoclonic epilepsy. Georgia Montouris and Bassel Abou-Khalil consider whether to use valproate first versus a new antiepileptic drug (AED). Tonic and atonic seizures belong to the category of very refractory seizure types, for which the consequences of frequent seizures include unprotected falls that can be devastating. Eileen P.G. Vining reviews the treatment options (including the ketogenic diet), and then William E. Rosenfeld and David W. Roberts present the pros and cons of using vagus nerve stimulation or callosotomy when other treatment fails. Absences seizures are very common in children but not so frequent in adults. There are currently no studies with a high level of evidence that can be helpful in determining which drug is the most efficacious in treating absence seizures. Some drugs, however, increase the rate of absence seizures; this adverse result of treatment is discussed in the article by Ernest R. Somerville. The next topic of concern is the controversy over whether a newer or older AED (e.g., valproate or ethosuximide) should be the first drug of choice for absences, as discussed by Patricia E. Penovich and L. James Willmore. The majority of patients with epilepsy have partial onset seizures. The remaining articles in this supplement deal with this type of seizure. Within this context, Scott Mintzer and Richard T. Mattson discuss whether an enzyme-inducing drug should be considered as a first-line drug or whether a drug that has no enzyme-induction property should be the first drug of choice for partial onset seizures. Although there is no obvious answer to this controversy, the pros and cons for each treatment choice will be presented in detail. Unfortunately, many patients with partial onset seizures are refractory to most AEDs. What can we do to help these patients and how should we proceed? Barbara C. Jobst presents possible treatment algorithms that are designed to guide the physician in choosing a strategy to treat the patient with refractory epilepsy. When treating refractory epilepsy, there is an ongoing debate about whether the physician should use more than two concomitant AEDs if the first two monotherapy attempts fail, or whether the physician should refer the patient directly for early surgical evaluation. Patrick Kwan and Michael R. Sperling discuss this problem in their article. When treating a patient with refractory epilepsy, the question always arises if there is such a thing as “rational” polytherapy. This issue was much discussed a decade ago, and has again become a hot topic of debate with the development of new AEDs with unique mechanisms of action. Now that we have so much information about the mechanisms of action of AEDs, the question of polytherapy can be somewhat reformulated to ask whether the choice of an additional AED can be made on the basis of mechanism of action that would “complement” the mechanism of action of the AED already in use—a question debated by Jacqueline A. French and Edward Faught. Finally Steven N. Roper discusses surgical treatments, focusing particularly on surgery for extratemporal epilepsy. What patients are candidates for this type of surgery, especially given that the procedures and the results are not nearly as straightforward as surgical therapy for temporal lobe epilepsy? This Annual Course Supplement provides the reader with key points from the 2008 AES Annual Course, helping the physician in the following therapeutic choices: Diagnosis of Dravet syndrome in patients with refractory seizures coupled with certain phenotypic signs. Increased knowledge about this syndrome should provide a basis for prescribing newer therapies for seizure reduction in these patients. Identification and evaluation of the pros and cons associated with treating (or not treating) “benign” epilepsy of childhood with rolandic spikes. Avoiding delays in offering advanced therapies to patients with atonic or tonic seizures that have proven refractory to front-line therapy. Selecting optimal therapy for absence seizures that offers the best chance at seizure reduction and the least chance for seizure aggravation. Selecting pharmacotherapy for juvenile myoclonic epilepsy in women of childbearing age that has the lowest risk for poor outcomes in future pregnancies. Selecting the best AED therapy for patients with partial onset seizures. Systemizing the steps in the diagnosis and treatment of refractory epilepsy, from simple drug treatment protocols to epilepsy surgery. We hope that the goals of the course—to increase the ability of physicians to offer optimal treatment to their patients—are enhanced by this supplement, which describes new (and hopefully more effective) ways to treat patients in order to improve their lives. Disclosure: The author declares no conflicts of interest.