Initial individualized selection of long-term anticonvulsant drugs by neurologists

Until 10 years ago the initial selection of anticonvulsant drug treatment was relatively straightforward. Partial seizures with or without secondary generalization were typically treated with phenytoin or carbamazepine. Phenobarbital was a second choice because of its sedating side effects. Valproate, which obtained a formal indication for partial seizure treatment in 1996, was sometimes used as a first- or second-line agent. Primarily generalized epilepsy, with either absence or myoclonic seizures or generalized tonic–clonic attacks with 3-per-second spike–wave discharges on the EEG, was typically treated with valproate. For pure absence, ethosuximide was an alternative choice, especially for young children. In the past 10 years, eight new agents for the treatment of epilepsy have been introduced to the United States market, and an additional agent, vigabatrin, has been available in Canada and Europe. Although there are subtle differences in the formal indications for each of these agents approved by the FDA and by European licensing authorities, all of them have demonstrated efficacy as adjunctive treatment of partial seizures with or without secondary generalization. Oxcarbazepine and felbamate have been approved as initial monotherapy (although felbamate is not currently used as first-line treatment), and lamotrigine has been approved for conversion to monotherapy. By contrast, none of the new agents has a formal indication for the treatment of absence and other forms of primarily generalized epilepsy, although topiramate is indicated for the treatment of generalized tonic–clonic seizures. Although FDA-approved indications are generally based on evidence obtained from randomized double-blind trials and typically guide the initial use of new therapeutic agents, they …