Cochrane for Clinicians

Putting Evidence into Practice

Antiepileptic Drug Monotherapy for Epilepsy

 

Am Fam Physician. 2018 May 1;97(9):572-573.

Author disclosure: No relevant financial affiliations.

Clinical Question

Which is the best antiepileptic drug monotherapy for adults and children with epilepsy?

Evidence-Based Answer

In patients with partial-onset (focal) seizures, levetiracetam (Keppra), lamotrigine (Lamictal), and carbamazepine (Tegretol) were associated with the longest time to treatment withdrawal (i.e., the recommended patient-oriented outcome measure that balances tolerability with effectiveness). In patients with generalized seizure disorder, valproic acid (Depakene) was associated with the longest time to treatment withdrawal.1 (Strength of Recommendation: A, based on consistent patient-oriented evidence.)

Practice Pointers

Approximately 1.2% of the U.S. population has active epilepsy, including 3 million adults and 470,000 children.2 Up to 70% of patients with epilepsy will attain remission with appropriate treatment, the majority with antiepileptic drug monotherapy.3,4 This analysis compared the effectiveness of 10 monotherapy antiepileptic drugs: carbamazepine, gabapentin (Neurontin), lamotrigine, levetiracetam, oxcarbazepine (Trileptal), phenobarbital, phenytoin (Dilantin), valproic acid, topiramate (Topamax), and zonisamide (Zonegran).

This Cochrane review included 36 randomized controlled trials with 12,391 patients. Patients of all ages were pooled for analyses; approximately 67% had partial-onset seizures, 25% had generalized-onset seizures, and 9% had unclassified seizures.1 The primary outcome was time to withdrawal of allocated treatment, with longer time to withdrawal indicating more successful therapy. Secondary outcomes were six- and 12-month remission of seizures, time to first seizure post-randomization, and treatment-related adverse effects. Outcomes were presented as Cox proportional hazard ratios (HRs), with HRs less than 1.0 being better and HRs greater than 1.0 being worse when compared with control drugs.1

In patients being treated for partial seizures, lamotrigine (HR = 0.75; 95% confidence interval [CI], 0.65 to 0.86) and levetiracetam (HR =

Author disclosure: No relevant financial affiliations.


The practice recommendations in this activity are available at http://www.cochrane.org/CD011412.

The views expressed in this article are the authors' and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences, the U.S. Army, the Department of Defense, or the U.S. government.

References

show all references

1. Nevitt SJ, Sudell M, Weston J, Tudur Smith C, Marson AG. Antiepileptic drug monotherapy for epilepsy: a network meta-analysis of individual participant data. Cochrane Database Syst Rev. 2017;(12):CD011412....

2. Centers for Disease Control and Prevention. Epilepsy. Data and statistics. Updated January 17, 2018. https://www.cdc.gov/epilepsy/data/index.html. Accessed April 2, 2018.

3. Liu G, Slater N, Perkins A. Epilepsy: treatment options. Am Fam Physician. 2017;96(2):87–96.

4. Manford M. Recent advances in epilepsy. J Neurol. 2017;264(8):1811–1824.

5. National Institute for Health and Care Excellence. Epilepsies: diagnosis and management. Clinical guideline 137. Updated February 2016. https://www.nice.org.uk/guidance/cg137. Accessed April 2, 2018.

These are summaries of reviews from the Cochrane Library.

This series is coordinated by Corey D. Fogleman, MD, Assistant Medical Editor.

A collection of Cochrane for Clinicians published in AFP is available at https://www.aafp.org/afp/cochrane.

 

 

Copyright © 2018 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP

More in Pubmed

MOST RECENT ISSUE


May 15, 2018

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article