Antiepileptic Drugs

Ideally, patients should be managed on a single drug that leads to complete seizure freedom without causing any side effects. Approximately 75% of patients with epilepsy can be fully controlled on monotherapy (50% with initial monotherapy and 25% with second monotherapy), with the choice of agent determined by the epilepsy syndrome and seizure type (Table VII). Carbamazepine and valproate are the recommended substances for simple, complex partial, and secondary generalized tonic-clonic seizures. For most generalized seizures, sodium valproate is the most useful treatment. These drugs are generally thought of as the first-line treatments. Of the remaining patients not controlled on monotherapy, addition of another firstline drug will gain control in 15%. However, some patients will develop chronic seizures unrelieved by these treatments. In such circumstances, alternative monotherapies or adjunctive therapies will be considered. Many of the recently introduced anticonvulsants, often considered as second-line treatments, may be introduced, either alone or in combination with a firstline agent.

In Europe and the United States, nine novel anticonvulsants have been introduced in the past decade: vigabatrin, lamotrigine, felbamate, tiagabine, gabapentin, oxcarbazepine, topiramate, levetiracetam, and zonisamide. Because of serious side effects, two of these drugs are used only in a highly selected group of patients. Felbamate has caused fatal hepatotoxic and

Table VII

Selection of Antiepileptic Drugs According to the Epileptic Syndrome

Type of syndrome

First-line drugs

Second-line drugs

All seizure types

Focal epilepsies

Carbamazepine Valproic acid

Lamotrigine

Gabapentin

Topiramate

Tiagabine

Levetiracetam

Oxcarbazepine

Phenytoin

Clobazam

Primidone

Acetazolamide

Vigabatrin

Felbamate

Idiopathic

Absences

Myoclonic

Generalized epilepsies

Ethosuximide Valproic acid Valproic acid

Awakening grand mal Valproic acid

Symptomatic

West syndrome

Vigabatrin

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