Selection Of Antiepileptic Drugs Research Articles

Drug utilization pattern of antiepileptic drugs and traditional Chinese medicines in a general hospital in Taiwan - a pharmaco-epidemiologic study.

Studies on antiepileptic drug utilization are important for the optimization of drug therapy and drug control. The present study was to evaluate the drug utilization pattern of standard antiepileptic drugs and traditional Chinese medicines (TCMs) in the treatment of different types of epilepsy in a general hospital in Taiwan. The epileptic patients under antiepileptic drug treatment at Veterans General Hospital-Taipei were considered in the analysis. Current diagnosis was obtained by the neurologist in charge of the patient. All patients were interviewed by standard questionnaire designed to provide specific information on the types of antiepileptic drugs and details of their use. The questionnaire also sought to determine whether TCMs were used, and whether patients were using TCMs in combination with hospital standard treatment. The results were analysed by descriptive statistics. 729 patients with epilepsy definitely diagnosed were analysed in the study. 445 patients (61.04%) were prescribed with one antiepileptic drug. Combinations of two antiepileptic drugs were prescribed to 261 patients (35.80%), and combinations of three or more antiepileptic drugs to 23 patients (3.16%). A total of 1039 antiepileptic drugs was prescribed, corresponding to an average 1.42 drugs per patient. The most frequently prescribed antiepileptic drug was carbamazepine (56.93%), followed by phenytoin (31.96%), valproate (30.73%) and clonazepam (14.13%). Among the 729 epileptic patients, 83.68% used standard antiepileptic drugs alone, 16.32% used antiepileptic drugs in combination with TCMs. Monotherapy is the type of therapy most frequently used in all types of seizures. The selection of antiepileptic drugs is based on efficacy for specific seizure types and epileptic syndromes. The most frequently prescribed antiepileptic drug was carbamazepine, followed by phenytoin, valproate and clonazepam. As some of the patients used TCMs for treatment of epilepsy even when scientific medicine has been provided, further studies on the possible interactions between TCMs and antiepileptic drugs are in progress.

Quality of life as an outcome measure for epilepsy clinical trials.

Assessment of health-related quality of life (HRQOL) has been developed to the point where well-validated instruments are being used in clinical trials. Data on the impact of new treatments can be used for formulary and regulatory decisions if the clinical trials are designed with appropriate instruments and sample sizes. However, more information is needed about the clinical significance of small differences in total or scale scores. Similarly, pharmacoeconomic studies should be prospective assessments that include evaluation of HRQOL as well as cost. In the future, these new aspects of outcome assessment are expected to be used as an adjunct to traditional seizure frequency and adverse effect reports in the selection of antiepileptic drugs.

Selection of antiepileptic drugs: a practical approach.

The selection of antiepileptic drugs (AEDs) is increasingly more complex as new agents become available. We discuss an individualized approach to selection of an AED that is tailored to each patient's needs by considering the following six factors: effectiveness of the drug in controlling seizures, adverse effects profile, pharmacokinetic properties, special or unique patient situations, drug interactions, and cost of treatment. When these factors are considered, treatment complications and failure can be minimized by anticipating incompatibilities among drugs or between the drugs and the patient's condition. We emphasize the concept that the best AED therapy is dependent on optimal seizure control and absence of unacceptable side effects. In the current environment of medical practice, the cost of treatment has also become a major concern. With rare exceptions, no single factor dictates the choice of an AED. In the long term, the most cost-effective treatment will be the one that provides the most therapeutic benefit with the fewest complications and maximal patient satisfaction.

Selection of Antiepileptic Drugs: A Practical Approach

The selection of antiepileptic drugs (AEDs) is increasingly more complex as new agents become available. We discuss an individualized approach to selection of an AED that is tailored to each patient's needs by considering the following six factors: effectiveness of the drug in controlling seizures, adverse effects profile, pharmacokinetic properties, special or unique patient situations, drug interactions, and cost of treatment. When these factors are considered, treatment complications and failure can be minimized by anticipating incompatibilities among drugs or between the drugs and the patient's condition. We emphasize the concept that the best AED therapy is dependent on optimal seizure control and absence of unacceptable side effects. In the current environment of medical practice, the cost of treatment has also become a mao jor concern. With rare exceptions, no single factor dictates the choice of an AED. In the long term, the most cost-effective treatment will be the one that provides the most therapeutic benefit with the fewest complications and maximal patient satisfaction.

Complex partial status epilepticus in childhood

We report 5 pediatric patients (2 male, 3 female; age range: 4–8 years) with complex partial status epilepticus (CPSE). Four patients had previous illnesses and mild motor or mental retardation. In 2 patients, CPSE was induced by inappropriate management or selection of antiepileptic drugs. Clinical features varied and automatisms were observed in 3 patients. In 1 patient, decreased physical tone with syncope and impaired consciousness with amaurosis were observed. The episodes of CPSE were continuous in 3 patients and recurrent in 2 patients. In 4 patients, ictal electroencephalographic (EEG) findings, including video-EEG analyses of 3 patients, demonstrated persistent focal epileptic features. Intravenous diazepam abolished CPSE in 3 patients with brief periods of definite EEG localizations remaining. In 4 patients, seizure prognoses were favorable after appropriate treatments; in 1 patient, seizures were intractable even after antiepileptic drug administration.

Efficacy and adverse effects of established and new antiepileptic drugs.

Antiepileptic drug (AED) selection is based primarily on efficacy for specific seizure types and epileptic syndromes. However, efficacy is often similar for the different AEDs, and other properties such as adverse effects, pharmacokinetic properties, and cost may also be of importance. For idiopathic generalized epilepsies with absence, tonic-clonic, and myoclonic seizures, the AED of choice is valproate (VPA). Secondarily generalized epilepsies with tonic, atonic, and other seizure types are difficult to treat with any single AED or combination of AEDs. The AEDs of choice for absence seizures are ethosuximide (ESM) and VPA. For control of primary generalized tonic-clonic seizures, any of the other major AEDs can be effective. If VPA cannot be prescribed, carbamazepine (CBZ), phenobarbital (PB), phenytoin (PHT), or primidone (PRM) may be effective, but ESM or a benzodiazepine (BZD) must be added to control associated absence or myoclonic seizures. The AEDs of first choice for partial epilepsies with partial and secondarily generalized tonic-clonic seizures are CBZ and PHT. Increasing evidence suggests that VPA is a good alternative when CBZ and PHT fail. PB and PRM are second-choice selections because of adverse effects. A combination of two of the five standard AEDs may be necessary to treat intractable seizures, but no studies have been done to indicate an optimal combination. Other epilepsy syndromes such as neonatal and infantile epilepsies, febrile epilepsy, alcoholic epilepsy, and status epilepticus require specific AED treatment. Ultimately, AED selection must be individualized. No "drug of choice" can be named for all patients. The expected efficacy for the seizure type, the importance of the expected adverse effects, the pharmacokinetics, and the cost of the AEDs all must be weighed and discussed with the patient before a choice is made. A number of new AEDs with unique mechanisms of action, pharmacokinetic properties, and fewer adverse effects hold important promise of improved epilepsy treatment.

Standard approach to antiepileptic drug treatment in the United Kingdom.

In the United Kingdom, the question of whether to commence antiepileptic drug (AED) treatment remains controversial. Surveys indicate that 15% of patients are treated after a first seizure. Pediatricians often wait for a third or fourth seizure before treating, whereas clinicians who deal with adult patients are more likely to intervene early, largely because of concerns about driving and employment. Monotherapy is becoming the rule for the majority of patients. The four primary AEDs in the United Kingdom are carbamazepine and phenytoin (approximately 30% each), valproate (VPA; approximately 25%), and phenobarbital (approximately 18%). For partial epilepsies, studies show few major differences in efficacy among these four AEDs. A firstline AED should be one, such as VPA, with a broad spectrum of activity that is easily managed by clinicians who may not have special expertise in the recognition of differing seizure types and epilepsy syndromes. Where differences in efficacy are marginal, comparative drug toxicity may be a major factor in AED selection. Most new AEDs have low toxicity profiles. With respect to discontinuation, pediatricians usually recommend a trial discontinuation period in most children who achieve a 1- or 2-year remission of epilepsy. For adults, however, overall relapse rates after discontinuation are approximately 40-50%; therefore, patients usually opt for long-term AED therapy.

Antiepileptic drug selection and adverse effects: an overview.

In choosing an antiepileptic drug, not only efficacy but also potential adverse effects have to be considered. Adverse effects that have to be taken into account include acute and chronic systemic toxicity, cognitive side effects, and teratogenesis. Acute toxicity may be dose-related, allergic or an idiosyncratic reaction. Chronic toxicity may involve the nervous system or other organs. In determining the role of new antiepileptic drugs such as lamotrigine, vigabatrin, felbamate, and gabapentin a proper evaluation of both efficacy and adverse effects is required.

Selection of Drugs for the Treatment of Epilepsy

Antiepileptic drug selection is based on efficacy for specific seizure types and epileptic syndromes. For idiopathic generalized epilepsies with absence, tonic-clonic, and myoclonic seizures, the drug of choice is valproate. Secondary generalized epilepsies with tonic, atonic, and other seizure types are difficult to treat with any single drug or combination of drugs. The drugs of choice for absence seizures are ethosuximide and valproate. For control of tonic-clonic seizures, any of the other major antiepileptic drugs can be effective. If valproate cannot be used, carbamazepine, phenobarbital, phenytoin, or primidone is effective, but ethosuximide or a benzodiazepine needs to be added to control associated absence or myoclonic seizures. The drugs of first choice for partial epilepsies with partial and secondarily tonic-clonic seizures are carbamazepine and phenytoin. Increasing evidence suggests that valproate may be a third alternative. Phenobarbital and primidone are second choice selections because of side effects. A combination of two of these five major antiepileptic drugs may be necessary for inadequately controlled patients. Other epilepsy syndromes such as neonatal and infantile epilepsies, febrile epilepsy, and alcoholic epilepsy require specific drug treatment. For all these seizure types and epilepsy syndromes, treatment ultimately must be selected to provide maximal efficacy and minimal adverse effect for each individual patient.

Delayed Speech: Developmental Mutism

There are 2 major categories of patients with seizures and chronic kidney disease (CKD): patients who develop acute symptomatic seizures in the setting of CKD and patients with epilepsy who at some point develop CKD. The incidence of uremic seizures with kidney failure is ∼10%. These seizures are often nonconvulsive and may mimic uremic encephalopathy. Recognition and management of such situations may be challenging for treating physicians who are non-neurologists. Furthermore, practitioners caring for patients with seizures with or without an established diagnosis of epilepsy in the setting of CKD frequently encounter challenges in the selection, loading, titration, and maintenance of antiepileptic drugs (AEDs) due to potentially altered pharmacokinetics of the AEDs. We review the pathophysiology of uremia, uremic seizures, and other neurologic complications of kidney failure; management approaches to the treatment of such complications; the relevant mechanisms of action and pharmacokinetics of AEDs with their use in CKD; and in particular, the management of AEDs in patients requiring hemodialysis therapy.