title: Prospective audits with newer antiepileptic drugs in focal epilepsy: insights into population responses?
abstract: Despite the availability of a wide range of new antiepileptic drugs (AEDs), there is little evidence that their introduction has substantially altered outcomes. This paper reviews data from 5 consecutive prospective audits with new AEDs using similar methodology. Prospective audits with topiramate (TPM; n=135), levetiracetam (LEV; n=136), zonisamide (ZNS; n=141), pregabalin (PGB; n=135), and lacosamide (LCM; n=160) were undertaken in treated patients with uncontrolled partial-onset seizures. Follow-up continued until one of four endpoints was reached: seizure freedom for ≥6months on unchanged dosing; ≥50% reduction (responder) in seizure frequency on the highest tolerated dose compared with baseline; <50% seizure frequency reduction (marginal response) compared with baseline in patients wishing to continue treatment with the new AED; or withdrawal due to lack of efficacy, side effects, or both. A greater proportion of seizure-free patients occurred with LEV (23.5%), LCM (21.9%), and TPM (20.7%) than with ZNS (12.8%) and PGB (10.4%). A higher percentage discontinued treatment with ZNS (41.8%) and PGB (50.4%) than with LEV (32.4%), TPM (31.1%), and LCM (22.5%). Most seizure-free patients responded to the new agent as first or second add-on (TPM 96%; LEV 97%; ZNS 89%; PGB 86%; LCM 97%) often at modest or moderate dosing (TPM 68%, ≤200mg/day; LEV 63%, ≤1000mg/day; ZNS 61%, ≤100mg/day; PGB 86%, ≤300mg/day; LCM 74%, ≤200mg/day). With <10% of patients discontinuing all AEDs due to lack of efficacy, tolerability was the major factor influencing the number of patients remaining on treatment. Lacosamide was the best (77% patients continued treatment), while PGB was the worst (50% continued treatment) tolerated AED. Overall, seizure freedom was achieved in <25% of patients in each audit, mainly as a first or second add-on, with best tolerated AEDs producing a higher number of good outcomes. Seizures in very few patients with drug-resistant epilepsy, as defined by the International League Against Epilepsy task force, responded to any of the 5 newer AEDs. These data support the suggestion that the introduction of modern agents has not importantly impacted the outcomes in refractory epilepsy.
authors.affiliation: Epilepsy Unit, Western Infirmary, Glasgow, Scotland, UK.
authors.forename: Martin J
authors.initials: MJ
authors.lastname: Brodie
authors.affiliation: Epilepsy Unit, Western Infirmary, Glasgow, Scotland, UK.
authors.forename: Kevin
authors.initials: K
authors.lastname: Kelly
authors.affiliation: Epilepsy Unit, Western Infirmary, Glasgow, Scotland, UK. Electronic address: linda.stephen@ggc.scot.nhs.uk.
authors.forename: Linda J
authors.initials: LJ
authors.lastname: Stephen
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000927:Anticonvulsants / Q000627:therapeutic use*; D018672:Community Health Planning; D004828:Epilepsies, Partial / Q000188:drug therapy*; D005260:Female; D006801:Humans; D008297:Male; D008485:Medical Audit / Q000379:methods*; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D011446:Prospective Studies; D013997:Time Factors; D055815:Young Adult
chemical_list: D000927:Anticonvulsants
keywords: Antiepileptic drug; Dose; Outcome; Prospective audit; Seizure freedom