Treatment Of Epilepsy In Adults Research Articles

Gabapentin for Seizures

What Is the Issue? Gabapentin is 1 of many antiseizure medications available for the treatment of epilepsy in adults; however, there are potential risks associated with its use. Therefore, it is important to determine the place of therapy of gabapentin in the treatment of epilepsy. What Did We Do? To help determine the potential place in therapy for gabapentin in the treatment of epilepsy in adults, we sought to identify and summarize studies of the clinical- and cost-effectiveness of gabapentin as well as recommendations from evidence-based guidelines. We searched key resources, including journal citation databases, and conducted a focused internet search for relevant evidence published since 2014. One reviewer screened articles for inclusion based on predefined criteria, critically appraised the included publications, and narratively summarized the findings. What Did We Find? We identified 1 systematic review and 1 randomized controlled trial (RCT) that evaluated the efficacy of gabapentin in adults with epilepsy. We identified 5 evidence-based guidelines that included recommendations on the use of gabapentin for epilepsy. We did not identify any studies that evaluated its cost-effectiveness. Seizure-free retention at 3 months may be better in adults with epilepsy who were treated with lamotrigine than gabapentin or carbamazepine. There were no differences in other seizure outcomes (such as time to seizure, seizure freedom, or seizure-free retention) for adults with epilepsy treated with gabapentin versus lamotrigine or carbamazepine. Adults with epilepsy treated with gabapentin were more likely to experience fair or poor health perception than those treated with oxcarbazepine. There were no differences in other quality of life outcomes (such as anxiety, depression, or worry about seizures) between those treated with gabapentin versus lamotrigine, carbamazepine, oxcarbazepine, or topiramate. Withdrawals because of adverse events were similar between adults with epilepsy treated with gabapentin and lamotrigine. There were more systemic toxicities in adults treated with gabapentin than carbamazepine or lamotrigine but there were no differences in neurotoxicities between groups. One guideline recommends against the use of gabapentin in people with myoclonic seizures or people with epilepsy with myoclonic-atonic seizures. One guideline states that there is insufficient evidence to consider gabapentin instead of carbamazepine in patients with new-onset focal epilepsy or unclassified generalized tonic-clonic seizures. Three guidelines recommend the use of gabapentin in older adults with epilepsy. One guideline recommends the use of gabapentin in people with intellectual disability and epilepsy, if the benefits outweigh the risks or as a second-line option. What Does It Mean? There were few differences in outcomes between adults with epilepsy treated with gabapentin versus other active comparators in the studies we identified. The included guidelines recommended for or against the use of gabapentin depending on patient factors such as age and type of epilepsy or seizures. Decision-makers may wish to consider individual patient factors such as age and type of epilepsy or seizures as well as the availability of other treatment options when making decisions on the use of gabapentin for the treatment of epilepsy.

Sodium Valproate-Induced Hyperammonemia: A Case Series in a Tertiary Care Hospital.

Sodium valproate (VPA) is an extensively used anti-convulsant, which is an effective drug for treatment of epilepsy in adults and children, as well as for conditions like migraine, bipolar disorder, mania, and trigeminal neuralgia. Sedation, vertigo, ataxia, dose-dependent tremors, headaches, and gastrointestinal side effects are the most often reported adverse effects associated with VPA. A potential life-threatening event reported with VPA is hyperammonemia (HA), which is defined as an increase in serum level of ammonia. Only 587 reported cases of HA were found in the VigiAccess database, representing a mere 0.6% of the 95,000 reported adverse events linked to VPA. Hence, this case series was conducted with emphasison monitoring of increased serum ammonia levels with or without hepatic enzymes increase for patients who are on VPA. To assess elevated serum ammonia levels following VPA administration, and to ascertain the percentage of individuals with hepatic enzymes increased who took VPA and subsequently had elevated serum ammonia levels. This study was conducted at the adverse drug reaction (ADR) monitoring centre (AMC) of the Pharmacovigilance Programme of India (PvPI) and Department of Psychiatry, Christian Medical College and Hospital (CMC&H), Ludhiana. The study comprised of 12 patients who were exclusively on VPA and exhibited symptoms related to elevated serum ammonia.An informed consent form (ICF) was provided to the patient prior to taking their personal details. Laboratory investigations were done to establish the diagnosis and liver function tests (LFTs), chiefly ALT (alanine transferase) and AST (aspartate aminotransferase) were also performed.It is a descriptive study which was for a time period of six months. Results: This study includes 12 patients who had HA confirmed by laboratory investigation. Out of these 12 patients, two patients (17%) had a corresponding increase in LFT. The average as of the patients was 53.08 years and average serum ammonia levels were 219.15. None of the patients who presented with HA progressed to hyperammonemic encephalopathy (HAE). This case series on valproate-induced HAshould be of interest to psychiatrists, physicians, internists, family medicine physicians, hospitalists, and surgeons who will have patients on VPA. Delay in recognition of HA can result in the development of potentially life-threatening complications.Rapid diagnosis and management will help in reducing the number of cases which progress to encephalopathy which is highly fatal.

The pharmacological treatment of epilepsy in adults.

The pharmacological treatment of epilepsy entails several critical decisions that need to be based on an individual careful risk-benefit analysis. These include when to initiate treatment and with which antiseizure medication (ASM). With more than 25 ASMs on the market, physicians have opportunities to tailor the treatment to individual patients´ needs. ASM selection is primarily based on the patient's type of epilepsy and spectrum of ASM efficacy, but several other factors must be considered. These include age, sex, comorbidities, and concomitant medications to mention the most important. Individual susceptibility to adverse drug effects, ease of use, costs, and personal preferences should also be taken into account. Once an ASM has been selected, the next step is to decide on an individual target maintenance dose and a titration scheme to reach this dose. When the clinical circumstances permit, a slow titration is generally preferred since it is associated with improved tolerability. The maintenance dose is adjusted based on the clinical response aiming at the lowest effective dose. Therapeutic drug monitoring can be of value in efforts to establish the optimal dose. If the first monotherapy fails to control seizures without significant adverse effects, the next step will be to gradually switch to an alternative monotherapy, or sometimes to add another ASM. If an add-on is considered, combining ASMs with different modes of action is usually recommended. Misdiagnosis of epilepsy, non-adherence and suboptimal dosing are frequent causes of treatment failure and should be excluded before a patient is regarded as drug-resistant. Other treatment modalities, including epilepsy surgery, neuromodulation, and dietary therapies, should be considered for truly drug-resistant patients. After some years of seizure freedom, the question of ASM withdrawal often arises. Although successful in many, withdrawal is also associated with risks and the decision needs to be based on careful risk-benefit analysis.

Treatment of epilepsy in adults: Expert opinion in South Korea

ObjectiveThe aim of this study was to gather the expert opinions of Korean epileptologists regarding the treatment of adult patients with epilepsy. MethodsA total of 42 neurologists who specialized in epilepsy were surveyed. They completed an online questionnaire describing multiple patient scenarios. Using these scenarios, they evaluated treatment strategies and gave their preference for specific antiepileptic drugs (AEDs) used to treat genetically mediated generalized epilepsy and focal epilepsy. ResultsInitial AED monotherapy, followed by a second form of alternative monotherapy or an add-on combination therapy, was the preferred treatment strategy. The experts reached consensus for 87.2% of the items. The most commonly selected AEDs for the initial monotherapy for patients with generalized epilepsy were levetiracetam or valproate. For those with focal epilepsy, levetiracetam, oxcarbazepine, or lamotrigine were the most popular selections. Ethosuximide was the treatment of choice only for patients with generalized epilepsy with prominent absence seizures. Levetiracetam was preferred as an add-on therapy for both generalized and focal epilepsy. For special populations of patients, such as elderly adults or those with comorbid diseases, levetiracetam or lamotrigine was selected as the treatment of choice. ConclusionMost of the survey results were in accordance with the US expert opinion survey published in 2016. This survey can assist clinicians in making clinical decisions when treating individual adult patients with epilepsy.

Current approaches to neurosurgical treatment for drug-resistant focal epilepsy in adults

The review is dedicated to the problems of current neurosurgical treatment for drug-resistant epilepsy in the adult population of Russia and foreign countries. The literature published in the period 2010–2017 was sought in Russian and foreign databases. This review included 58 only full-text publications. The search results have shown that despite advances in neurosurgery for drug-resistant epilepsy and the development of new surgical procedures, the problem of this disease has not yet been fully resolved today. This is evidenced by fairly high global prevalence rates in patients with postoperative epilepsy resistant to antiepileptic therapy. The literature analysis has revealed that the mean prevalence of postoperative epilepsy is 69%. This indicator may vary according to the type of an epileptogenic structural lesion and its location in the brain. However, despite the rapid development of epilepsy surgery, currently there is still a low surgical activity in the treatment of patients with drugresistant epilepsy. Of importance is also the presence of postoperative complications, including various infectious complications and neurological deficit. Taking into account the high rate of postoperative epilepsy, it is concluded that it is appropriate to develop postoperative rehabilitation methods for patients with drug-resistant epilepsy.

Epilepsy treatment in adults and adolescents: Expert opinion, 2016.

There are over twenty anti-seizure medications and anti-seizure devices available commercially in the United States. The multitude of treatment options for seizures can present a challenge to clinicians, especially those who are not subspecialists in the epilepsy field. Many clinical questions are not adequately answered in double-blind randomized controlled studies. In the presence of a knowledge gap, many clinicians consult a respected colleague with acknowledged expertise in the field. Our survey was designed to provide expert opinions on the treatment of epilepsy in adults and adolescents. We surveyed a group of 42 physicians across the United States who are considered experts based on publication record in the field of epilepsy, or a leadership role in a National Association of Epilepsy Centers comprehensive epilepsy program. The survey consisted of 43 multiple-part patient scenario questions and was administered online using Redcap software. The experts provided their opinion on 1126 treatment options based on a modified Rand 9-point scale. The patient scenarios focused on genetically-mediated generalized epilepsy and focal epilepsy. The scenarios first focused on overall treatment strategy and then on specific pharmacotherapies. Other questions focused on treatment of specific patient populations (pregnancy, the elderly, patients with brain tumors, and post organ transplant patients), epilepsy patients with comorbidities (renal and hepatic disease, depression), and how to combine medications after failure of monotherapy. Statistical analysis of data used the expert consensus method. Valproate was considered a drug of choice in all genetically-mediated generalized epilepsies, except in the population of women of child-bearing age. Ethosuximide was a drug of choice in patient with absence seizures, and levetiracetam was a drug of choice in patients with genetic generalized tonic-clonic seizures and myoclonic seizures. Lamotrigine, levetiracetam and oxcarbazepine were considered drugs of choice for initial treatment of focal seizures. Lamotrigine and levetiracetam were the drugs of choice for women of child-bearing age with either genetic generalized epilepsy or focal epilepsy. Lamotrigine and levetiracetam were the drugs of choice in the elderly population. Lamotrigine was preferred in patients with co-morbid depression. Levetiracetam was the drug of choice in treating patients with hepatic failure, or who have undergone organ transplantation. Compared to the 2005 and 2001 surveys, there was increased preference for the use of levetiracetam and lamotrigine, and decreased preference for the use of phenytoin, gabapentin, phenobarbital and carbamazepine. The study presented here provides a "snapshot" of the clinical practices of experts in the treatment of epilepsy. The experts were very often in agreement, and reached consensus in 81% of the possible responses. However, expert opinion does not replace the medical literature; instead, it acts to supplement existing information. Using the study results is similar to requesting an expert consultation. Our findings suggest options that the clinician should consider to achieve best practice.

FOCAL EPILEPSIES: PATHOMORPHOSIS TYPES

Background . Pathomorphosis of epilepsy is a process of the disease picture transformation due to environmental factors. It can be a result of natural evolution associated, for example, with genetic mutations, which makes it stable. It can also be caused by some artificial factors, such as pharmacotherapy. The article describes the most typical changes in the clinical picture of focal epilepsy induced by the main «engines of pathomorphosis» and affecting all periods of the disease: seizures, post-seizure and intra-seizure periods. Objective : to increase the efficacy of treatment of focal epilepsy in adults taking into account specific features of the disease pathomorphosis. Materials and methods . We enrolled 70 patients with focal epilepsy (mostly drug-resistant), who sought special medical assistance. The sample included 31 males (44 %) and 39 females (56 %) aged between 18 and 78 years. Results . In 76 % of patients in the general group, new types of seizures appeared. Of these, in 85 % of cases a new types of seizure have been added to existing ones. In 15 % of cases, seizures of the same type were replaced by another type. In 87 % of patients, a change in the incidence of relapse in the history was detected. «Migration of the seizures» during the day was observed in 19 % of cases. Cognitive disorders of varying severity were observed in 48 % of patients. Anxiety-depressive disorders were detected in 42 % of cases. The remission period in history for 12 months with subsequent relapse was observed in 27 % of patients in the general group. Of these, in 88 % of cases, remission was the result of using antiepileptic drugs, and 53 % of relapses were caused by their unjustified cancellation. Aggravation of seizures was observed in 9 % of patients in the general group. During the study, 91 % of patients were drug-resistant, of whom 64 % had severe secondarily generalized seizures. Non-compliance was detected in 47 % of cases. Conclusions. The variant of epilepsy pathomorphosis is determined by the complex of environmental factors. Antiepileptic pharmacotherapy is the most significant factor that requires further study, as well as other factors.

Treatment of epilepsy in adults.

Epilepsy is a chronic neurological disorder in adults and requires treatment with antiepileptic medication. While the majority of patients with epilepsy can be treated with medication, about one third will fail on medical treatment. Therefore, other treatment options such as surgery, devices, and the ketogenic diet are other options to consider, in addition to medical treatment. The treatment of epilepsy requires many other factors to be taken into consideration, and these include, but are not limited to, age, gender, coexistent medical conditions, and the use of concomitant medications. The goal of treatment is to provide optimal seizure control while using the least possible number of medications, particularly for young females at reproductive age or the elderly who may suffer from other medical diseases and receive other concomitant medications. Certain conditions may co-exist with epilepsy, such as migraine, mood disorder, and memory disturbances, therefore the decision to choose the most appropriate medication for epilepsy patients should also involve treatment of these conditions. Here, we review current clinical practice in epilepsy and focus on the most common problems and conditions that clinicians face on a daily basis to treat adult patients with epilepsy. Side effect profiles, spectrum of efficacy and optimal choices per predominant type of seizures are summarized and can be used for educational purposes.

Plant-Derived and Endogenous Cannabinoids in Epilepsy.

Cannabis is one of the oldest psychotropic drugs and its anticonvulsant properties have been known since the last century. The aim of this review was to analyze the efficacy of cannabis in the treatment of epilepsy in adults and children. In addition, a description of the involvement of the endocannabinoid system in epilepsy is given in order to provide a biochemical background to the effects of endogenous cannabinoids in our body. General tolerability and adverse events associated with cannabis treatment are also investigated. Several anecdotal reports and clinical trials suggest that in the human population cannabis has anticonvulsant properties and could be effective in treating partial epilepsies and generalized tonic-clonic seizures, still known as "grand mal." They are based, among other factors, on the observation that in individuals who smoke marijuana to treat epilepsy, cessation of cannabis use precipitates the re-emergence of convulsive seizures, whereas resuming consumption of this psychotropic drug controls epilepsy in a reproducible manner. In conclusion, there is some anecdotal evidence for the potential efficacy of cannabis in treating epilepsy. Though there has been an increased effort by patients with epilepsy, their caregivers, growers, and legislators to legalize various forms of cannabis, there is still concern about its efficacy, relative potency, availability of medication-grade preparations, dosing, and potential short- and long-term side effects, including those on prenatal and childhood development.

Alternative of Shortage Lorazepam in Case of Status Epilepticus

A suitable alternative to lorazepam in status epilepticus (SE) is understandable given the shortage of the injection formulation arising from manufacturing problems. I have consulted certain professional literature relating to this matter, including Section 4.8.2 of the British National Formulary (BNF, 2011) which describes drugs used in SE and the recently update guidelines from the National Institute for Clinical Excellence (NICE) which describe treatment of epilepsy in adults and children in primary and secondary care (NICE, 2012). This latter publication has been augmented with an online flowchart with a section specifically relating to treating convulsive SE in adults and children [1]. This is an invaluable consultation tool, to which you may want to refer. Additionally, two Cochrane reviews investigating whether a particular anticonvulsant is more effective or safer than another in treating SE in adults and children [2,3] provide the most relevant, up-to-date research on drug therapy for SE.

The most cited and downloaded papers in Epilepsy & Behavior over its first 15 years

2003 Psychogenic nonepileptic seizures: Review 2003 Rates and risk factors for suicide, suicidal i suicide attempts in chronic epilepsy 2000 The use of sertraline in patients with epile 2008 The global burden and stigma of epilepsy 2000 A pilot study of mood in epilepsy patients nerve stimulation 2005 Treatment of epilepsy in adults: Expert op 2005 Anxiety in patients with epilepsy: Systema suggestions for clinical management 2003 Epilepsy and cognition 2004 Cognitive side effects of antiepileptic drug 2002 The role of subcortical structures in human

Efficiency and tolerance of sustained-release valproate sodium (Depakine®ChronosphereТМ) as the drug of the first choice in the treatment of adult epilepsy

Objective: to obtain additional Russian data on the efficacy of Depakine®ChronosphereTMas a first-line agent for monotherapy in the treatment of adult epilepsy. Patients and methods. The short-term open-label prospective observational study that maximally approximated to routine clinical practice was conducted. The follow-up of patients lasted 2 months. The study included 494 patients over 18 years of age (mean age 30.2±14.1 years) with different types of epilepsy. Symptomatic focal epilepsies were noted in 52% of all cases, presumably symptomatic and idiopathic generalized epilepsies in 16.8 and 29.8%, respectively; unspecified ones in 1.4% of cases. The patients received Depakine Chronosphere in an average daily dose of 18.58±5.53 mg/kg. The efficacy of the drug was evaluated from the change in the number of seizures; moreover, subjective assessments of therapeutic effectiveness were made by a physician and a patient. The safety was estimated from patients' reports on adverse reactions during the follow-up. Results. More than 90% of all the patients responded to Depakine Chronosphere positively (seizures ceased or decreased in number). Seizures completely disappeared in 64.6% of the patients. The drug was proven to be effective in different types of epilepsy (both partial and generalized ones). Depakine Chronosphere was well tolerated in this study. Adverse events were observed in 15.7% of the patients, but they gave grounds to discontinue the drug only in 0.8% of all cases. The physicians and patients unanimously assessed the efficiency of therapy as very good and good in over 90% of cases. The good efficacy and tolerance of the agent are supported by the data of an analysis using the global clinical rating scale: during the treatment, there was a marked improvement and no side effects in 61.1% and a marked improvement and mild side effects in 17%. Conclusion. The study has indicated that Depakine Chronosphere monotherapy for adult epilepsy is effective and safe and a promising treatment.

Treatment of epilepsy in adults

No abstract available

Treatment of epilepsy in adults: Expert opinion in China

ObjectiveThe goal of this study was to survey a group of epileptologists in China regarding the treatment of adult epilepsy. MethodsA questionnaire on treatment of adult epilepsy was sent to a group of opinion leaders in the field of epilepsy. ResultsFor initial monotherapy for idiopathic generalized epilepsy (IGE), valproate was rated as the treatment of choice. In symptomatic localization-related epilepsy (SLRE)/simple partial seizures and SLRE/complex partial seizures, carbamazepine and oxcarbazepine were the respective treatments of choice, whereas in SLRE/secondarily generalized tonic–clonic seizures, carbamazepine, lamotrigine, and oxcarbazepine were treatments of choice. For women who were pregnant or trying to conceive, lamotrigine was the treatment of choice for both IGE and SLRE. In people with epilepsy who were HBsAg positive, whether liver function was normal or not, topiramate and levetiracetam were treatments of choice for IGE. Valproate and levetiracetam were treatments of choice for seizures in the emergency department. ConclusionA high level of consensus was reached on most treatments of choice and first-line treatments for patients with epilepsy, which were in accordance with published US expert opinion.

Pharmacoeconomic analysis of cost-benefit in evaluating the effectiveness of treatment for epilepsy in adults

The investigation evaluated the clinicoeconomic benefits of epilepsy therapy performed by a district neurologist versus an epileptologist in the outpatient setting. The index «cost-benefit» was calculated for different types of epileptic seizures in employed and unemployed patients before and after therapy optimization. Even if there was a considerable increase in direct costs after correction of antiepileptic therapy, the cost of patient management was shown to decrease by 2-3 times on average irrespective of the type of a seizure.

RUSSIAN OBSERVATIONAL SURVEY OF THE SHORT-TERM EFFICACY AND TOLERABILITY OF SUSTAINED-RELEASE SODIUM VALPROATE (DEPAKINE CHRONOSPHERA®) AS A FIRST-LINE DRUG IN THE TREATMENT OF EPILEPSY

Objective . To have additional data on the short-term safety and efficacy of sustained-release valproate (Depakine Chronosphera®, Sanofi- Aventis, France) used as both first-line monotherapy and additional therapy in children and adolescents with epilepsy. Subjects and methods . This open-label, noncomparative, prospective, short-term survey enrolled 1010 patients aged 1 month and 72 years (mean age 10,9±12,4 years). Three hundred (29,7%) patients had unspecified epilepsy; 40 (3,96%) had idiopathic focal epilepsy; 428 (42,38%) had presumptively symptomatic and symptomatic focal epilepsy; 117 (16,93%) had idiopathic generalized epilepsy, 71 (7,03%) had epileptic encephalopathy; 52 (5,15%) had West's syndrome. The starting dose of Depakine Chronosphera® was 10-15 mg/day; the mean therapeutic dose was 20-30 mg/kg/day. When there was no adequate response, the dose might be increased up to 50-60 mg/kg/day, by meticulously monitoring a patient's status. Depakine Chronosphera® was used both alone and in combination with other antiepileptic drugs (AED). The follow-up lasted at least 2 months. Results . The most common reason for using Depakine Chronosphera® was ineffective previous treatment with AED (24,7% of cases) and easiness to use. Due to the therapy, epileptic seizures ceased in 405 (40,1%) patients; their number reduced by 75 and 50% in 248 (24,55%) and 272 (26,93%) patients, respectively; therapy failed in 55 (5,45%) patients; seizure aggravation was noted in 7 (0,69%); there was no information on changes in the frequency of seizures in 23 (2,28%). Since Depakine Chronosphera® is intended mainly for both preschool children and older patients who have difficulties in taking the drug as tablets, the study group comprised children less than 7 years of age. Nevertheless, the drug was also actively given to children over 7 years and adults. This was associated with not only with the physician's interest in the new formulation of the drug, but also with its easiness to use. Adverse reactions were observed in 8,91% of the patients. The spectrum and frequency of side effects corresponded to those in the similar studies. Conclusion . The study has indicated that the use of Depakine Chronosphera® as monotherapy and multimodality treatment for epilepsy in adults and children is effective and safe. The low discontinuance rate of the drug suggests its good tolerability and efficacy, as well as easiness to use, in early preschool children in particular. The use of Depakine Chronosphera® is promising in treating epilepsy in adults and children

Long-term levetiracetam treatment in patients with epilepsy: 3-year follow up

To assess the long-term efficacy and tolerability of levetiracetam in routine clinical practice. We retrospectively analysed 218 patients, mostly adults, presenting mostly with localisation-related epilepsy, treated with levetiracetam as adjunctive therapy or monotherapy for up to 36 months. The primary points evaluated were: long-term retention rate, reasons for discontinuing levetiracetam and the percentage of seizure-free patients. The retention rate at 6, 12, 24 and 36 months following the commencement of levetiracetam treatment was 91.7, 75.2, 60.1 and 53.7% respectively. Sixty-seven (30.7%) patients discontinued levetiracetam treatment. During the clinical audit evaluation period, surgical resection or implantation of VNS was performed in 31 (14.3%) patients. In 53 of the 67 patients (79.1%), the treatment was discontinued due to lack of efficacy; in 14 patients (20.9%) treatment was discontinued due to adverse events. In total, 24 of 218 patients (11.0%) were seizure-free for 36 months. Levetiracetam is an effective and well-tolerated option for long-term treatment of epilepsy in adults.

Role of valproate across the ages. Treatment of epilepsy in adults

A workshop was held in Göteborg in June 2005 to discuss the place of valproate in treating adult epilepsies. Consensus positions were developed on the epilepsy types for which the drug is most suitable and the use of valproate in women of child-bearing age, in men and in patients with psychiatric comorbidity. Valproate was considered to be effective across a broad variety of epilepsy syndromes and seizure types and should be considered a suitable choice for first-line monotherapy of juvenile myoclonic epilepsy and other idiopathic generalized epilepsies. The use of valproate by women of child-bearing age is associated with potential harm to the foetus. A conservative approach to treatment is recommended in these patients whereby alternative antiepileptic drugs should be proposed to women planning pregnancies wherever satisfactory seizure control can be thereby maintained. In cases where valproate is used during pregnancy, either because the pregnancy was unplanned or because alternative treatment options of equivalent efficacy are unavailable, appropriate counselling, precautionary measures and monitoring should be provided. The evidence for an impact of valproate on male reproductive health is equivocal and considerations of male fertility should not be taken into account in deciding whether to prescribe valproate to men. Valproate can be proposed safely to patients with comorbid psychiatric disease or underlying psychiatric vulnerability.

Treatment of epilepsy in adults: expert opinion, 2005

Rationale Over the past decade, there has been a proliferation of new therapies for the treatment of epilepsy. Faced with this growing list of options, clinicians must decide what therapy, or combination of therapies, is best for a given individual. Although controlled clinical trials exist for each treatment option, the answer to these questions may remain unclear. In 2000, a survey of expert opinion was done to address questions concerning which treatment options might be best in a number of clinical situations. We surveyed a group of US epileptologists again in 2004 and compared the results of the two surveys. Methods We sent a questionnaire on the treatment of adolescent and adult epilepsy syndromes to a group of opinion leaders in the field of epilepsy. The questions were formatted to simulate real-world clinical situations in the treatment of symptomatic localization related epilepsy (SLRE) and idiopathic generalized epilepsy (IGE). The experts were asked to rate treatment options based on a modified RAND 9-point scale (with “9” most appropriate and “1” least appropriate). Statistical analysis of data was performed as defined by the expert consensus method. The results were used to develop user-friendly recommendations concerning overall treatment strategies and choice of specific medications. Results Of the 48 experts to whom the survey was sent, 43 (90%) responded; 29 (67%) of the respondents had also participated in the first survey. For initial monotherapy for IGE (generalized tonic-clonic [GTC], absence, and myoclonic seizures), valproate was rated as treatment of choice. For IGE-GTC seizures, lamotrigine and topiramate were also identified as usually appropriate for initial monotherapy. For IGE-absence seizures, ethosuximide was also a treatment of choice, and lamotrigine was usually appropriate. For SLRE, the experts were again asked to rate treatment options based on seizure type: simple partial seizures (SPS), complex partial seizures (CPS), and secondarily generalized tonic-clonic seizures (SGTC). In SLRE-SPS and SLRE-SGTC, carbamazepine and oxcarbazepine were treatments of choice, with lamotrigine and levetiracetam also usually appropriate. In SLRE-CPS, carbamazepine, lamotrigine. and oxcarbazepine were treatments of choice, while levetiracetam was also usually appropriate. For women who are pregnant or trying to conceive, lamotrigine was treatment of choice for both syndrome types. In the elderly, whether medically stable or ill, the treatment of choice was lamotrigine, while levetiracetam was also usually appropriate (along with gabapentin for persons with comorbid medical illness). In persons with HIV and epilepsy, lamotrigine and levetiracetam were usually appropriate. In people with both epilepsy syndromes who have depression, lamotrigine was treatment of choice. In a person with seizures and renal disease, lamotrigine was usually appropriate for both syndromes, with valproate also usually appropriate for IGE. In patients with hepatic disease, levetiracetam and lamotrigine were usually appropriate for IGE; in SLRE, levetiracetam was treatment of choice, with gabapentin also usually appropriate. Conclusions Although the panel of experts reached consensus on many treatment options, there are limitations to these types of data. Despite this, the expert consensus method concisely summarizes expert opinion, and this opinion may be helpful in situations in which the medical literature is scant or lacking. The information in this report should be evaluated in conjunction with evidence-based findings.

Treatment of Lennox-Gastaut Syndrome

Lennox-Gastaut syndrome (LGS) is a complex epilepsy of childhood characterised by an EEG demonstrating slow spike and wave complexes, multiple seizure types and cognitive impairment. Control of seizures is difficult, and the effectiveness of established anticon-vulsants is often disappointing. In the past few years, many new medications have been introduced for the treatment of partial epilepsy in adults. Emerging evidence suggests that some of these agents are also useful in LGS. Felbamate has been shown to be effective in a large controlled clinical trial, although its use is limited by life-threatening idiosyncratic reactions. Lamotrigine and topiramate have recently been shown in prospective controlled trials to be beneficial and well tolerated in patients with LGS. Vigabatrin appears to be particularly useful in children with underlying tuberous sclerosis. Novel neuroprotective strategies may be tested in the near future. The ketogenic diet has empirical efficacy in some children with intractable seizures. Vagal nerve stimulation is currently being tested in LGS, and preliminary data are encouraging. Anterior callosotomy may provide an improved quality of life in children with frequent ‘drop attacks’. These pharmacological and nonpharmacological approaches to the treatment of LGS offer new hope to patients and their families.