The evidence-based rationale formonotherapy in appropriate patientswith epilepsy Treatment of newly diagnosed epilepsy with a ing an appropriate, safe, and effective treatment single antiepileptic drug (AED) is now the favored strategy. For newly diagnosed partial seizures in approach for seizure management. The emer- adults and adolescents, the American Academy of Address correspondence andreprint requests to Dr. Rajesh gence of monotherapy as a mainstay treatment re- Neurology (AAN) guidelines recommend mono- sulted from studies that demonstrated the therapy with oxcarbazepine, lamotrigine, gabap- Neurology, UMDNJ RWJMedical School, Director effectiveness and advantages of a single AED in entin, or topiramate, or with an older “standard” controlling seizures. Monotherapy is usually as- AED such as carbamazepine, phenytoin, pheno- University Medical Center, 1945State Route 33, Neptune, NJ sociated with fewer potential problems such as barbital, or valproate. The International League toxicity, teratogenicity, and drug– drug interac- Against Epilepsy (ILAE) guidelines recommend tions, and is generally less expensive and easier to carbamazepine and phenytoin as monotherapy Neurology® 2007;69(Suppl 3):S1–S2
administer than polytherapy. Furthermore, the and regard oxcarbazepine, gabapentin, lam- vast majority of patients can achieve adequate sei- otrigine, phenobarbital, topiramate, and vigaba- zure control with the use of a single AED, and trin as possibly efficacious. The AAN also patients converted to monotherapy after having recommends monotherapy with oxcarbazepine or done poorly on polytherapy frequently show im- topiramate for patients with refractory partial ep- proved seizure control and experience fewer ad- ilepsy. In view of the special health issues associ- verse effects. These findings and other advantages of monotherapy have contributed to the general guidelines recommend AED monotherapy at the failure of the concept of rational polytherapy and lowest possible dose, with drug choice based on the acceptance of AED monotherapy as first-line seizure type, seizure control, and avoidance of treatment for most patients with epilepsy.
The expanding assemblage of AEDs provides Management of pediatric epilepsy requires useful new pharmacologic tools with great potential consideration of development-related issues in for improving patients’ quality of life. However, the addition to efficacy. An expert panel of physi- selection of an appropriate AED for initiation of cians treating pediatric epilepsy recently recom- monotherapy requires careful assessment of the mended oxcarbazepine and carbamazepine as risk– benefit profiles of different agents, including treatments of choice for initial monotherapy of consideration of drug efficacy, tolerability, safety, complex partial seizures and valproate as the pharmacokinetics, ease of use, and cost. Moreover, treatment of choice for symptomatic myoclonic the pharmacologic management of epilepsy in spe- and generalized tonic– clonic seizures (except in cial patient populations presents unique challenges the very young). The ILAE guidelines also recom- and requires consideration of parameters specific to mend oxcarbazepine as initial monotherapy for each patient. Recently published treatment recom- newly diagnosed or untreated partial-onset sei- mendations provide guidance for the selection of zures in children, based on level A evidence. The monotherapy options for adults, the elderly, chil- AAN guidelines recommend initial treatment of dren, and women of reproductive age.
newly diagnosed partial epilepsy in children with Guideline-based recommendations for the se- standard drugs or with the newer drugs lam- lection of AEDs can assist physicians in formulat- otrigine, gabapentin, oxcarbazepine, or topira- From the Department of Neurology, University of Medicine and Dentistry of New Jersey (UMDNJ), Epilepsy Program, Jersey Shore MedicalCenter, Neptune, New Jersey.
This supplement was supported by an educational grant from Novartis Pharmaceuticals Corporation.
Disclosure: The author reports no conflicts of interest.
Neurology® supplements are not peer-reviewed. Information contained in Neurology® supplements represents the opinions of the authors.
These opinions are not endorsed by nor do they reflect the views of the American Academy of Neurology, Editor-in-Chief, or Associate Editorsof Neurology®.
Copyright 2007 by AAN Enterprises, Inc.
mate. In particular, lamotrigine is effective for indicated as initial monotherapy in patients 10 years children with newly diagnosed absence seizures, or older with partial-onset or primary generalized gabapentin is effective in the treatment of newly diagnosed partial epilepsy, and lamotrigine, ox- This supplement reviews the clinical applica- carbazepine, and topiramate are effective in a tion of AEDs approved for monotherapy and the mixed population of newly diagnosed partial and therapeutic benefits of their use in adults and in generalized tonic– clonic seizures. Oxcarbazepine, special patient populations. The latest recom- topiramate, or lamotrigine are recommended as mendations for use of new AEDs, strategies for monotherapy in patients with refractory partial epi- conversion from polytherapy to monotherapy, is- lepsy. Of the new AEDs, oxcarbazepine is indicated sues relating to the design of monotherapy clini- by the US Food and Drug Administration for use as cal trials, and animal models for the identification monotherapy in the treatment of partial seizures in of new AEDs and the use of AEDs in combination children aged 4 years and older, and topiramate is


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