© 2014 direct one communications, inc. all rights reserved. 1 treating the new-onset epilepsy...

© 2014 Direct One Communications, Inc. All rights reserved. 1

Treating the New-Onset Epilepsy Patient

Ching Y. Tsao, MD

Emory University Hospital, Atlanta, Georgia

A REPORT FROM THE 67TH ANNUAL MEETING OF THE AMERICAN EPILEPSY SOCIETY (AES 2013)


What Is New-Onset Epilepsy?

New-onset epilepsy: early stage of epilepsy; more than two seizures within a single year

Newly diagnosed epilepsy: subtle seizures may have gone unrecognized for years prior to presentation

Pohlmann-Eden B. Epilepsia. 2012;53:1277


Factors Involved in Clinical Decisions

Mulrow CD et al. Ann Intern Med. 1997;126:389


Considerations When Choosing an AED

Patient-specific variables: genetics, age, gender, comorbidities, other medications

Antiepileptic drug (AED)-specific variables: efficacy for a particular type of seizures or syndromes, pharmacokinetics, adverse effects, teratogenicity, interaction potential

Country-specific variables: availability of AEDs, cost, insurance coverage

Glauser T et al. Epilepsia. 2006;47:1094


New-Onset Epilepsy in Adults

For treating partial-onset seizures: carbamazepine, phenytoin, levetiracetam, or zonisamide

For treating generalized onset seizures: valproate or ethosuximide» Limited evidence

» Recommendation based on one class I study for the treatment of absence seizures

Glauser T et al. Epilepsia. 2013;54: 551


Identifying New-Onset Epilepsy in Children

First challenge is recognition of seizures versus nonepileptic paroxysms

In one study, one-fourth of children were misdiagnosed as having seizures

At the same time, the diagnosis of epilepsy was missed in one-third of the children.

Hamiwka LD et al. Epilepsia. 2007;48:1062; Crompton DE, Berkovic SF. Lancet Neurol. 2009;8:370


Treating New-Onset Epilepsy in Children

Focal seizures: oxcarbazepine, carbamazepine, lamotrigine, or levetiracetam

Primary generalized epilepsies:» Childhood and juvenile absence epilepsies:

ethosuximide, valproate, or lamotrigine

» Juvenile myoclonic epilepsy: clonazepam, lamotrigine, levetiracetam, topiramate, valproate, zonisamide

Lennox-Gastaut syndrome (LGS): valproate, topiramate, lamotrigine, zonisamide, clobazam, rufinamide, or felbamate

Mulrow CD et al. Ann Intern Med. 1997;126:389; Glauser T et al. Epilepsia. 2013;54:551; Scottish International Guidelines Network (http://www.sign.ac.uk/guidelines/fulltext/81/)


Recommended Treatment of Childhood Focal Seizures

Wheless JW et al. Epileptic Disord. 2007;9:353; Wheless JW et al. J Child Neurol. 2005;20:S1


Treating New-Onset Epilepsy in Children

Age-specific issues:» Valproate: risk of hepatotoxicity in children < 2

years of age

» Topiramate: risk of appetite suppression

» Phenobarbital: negative impact on cognition

Sankar R. Neurology. 2004;63:S30


New-Onset Epilepsy in the Elderly

Incidence of epilepsy increases after age 50. Most cases of new-onset epilepsy in patients

over age 65 (51%) are cryptogenic.

Stroke (38%) and degenerative processes (12%) are also common etiologic or precipitating factors.

7%–21% of patients with Alzheimer’s disease have at least one unprovoked seizure.

43% of patients with stroke have recurrent seizures.» The risk increases with late onset of a first seizure

after stroke, a hemorrhagic component, occipital location, or low Rankin score after initial seizure

Hauser WA et al. Epilepsia. 1993;34:453; Amatniek JC et al. Epilepsia. 2006;47:867; Berges S et al. Eur Neurol. 2000;43:3


New-Onset Epilepsy in the Elderly

Hauser WA et al. Epilepsia. 1993;34:453

Age-specific incidence of epilepsy by gender in Rochester, Minnesota


Treatment of New-Onset Epilepsy in the Elderly

Therapeutic window is narrower in older adults» Risk of toxicity with AEDs at lower serum

concentrations

Seizure control comparable among gabapentin, lamotrigine, and carbamazepine in one study» A high rate of discontinuation of carbamazepine

due to adverse effects was observed

Data were obtained prior to the availability of levetiracetam

Bergey GK. Neurology. 2004;63(suppl 4):S40; Cloyd J, in: Rowan AJ, Ramsay RE, eds. Seizures and Epilepsy in the Elderly. Boston: Butterworth-Heinemann, 1997;219; Rowan AJ et al. Neurology. 2005;64:1868


The more seizures that occurred prior to initiation of AED therapy, the more difficult the epilepsy became to control.

The number of AEDs previously attempted and that had failed may predict future response to AEDs.

The addition of a second and a third AED increases the likelihood of seizure freedom only slightly.

SANAD Trial: Prognosis for New-Onset Epilepsy

Bonnett L et al. Lancet Neurol. 2012;11:331


Cumulative Probability of Being Seizure Free

Brodie MJ et al. Neurology. 2012;78:1548


Two-thirds of patients with epilepsy are seizure free after the first year of treatment.

More-favorable prognosis for seizure freedom: childhood absence epilepsy, benign rolandic epilepsy

Less-favorable prognosis for seizure freedom: juvenile absence epilepsy, symptomatic generalized epilepsy, mesial temporal sclerosis

Predictors of seizure freedom: number of seizures that have occurred, number of AEDs previous attempted

Seizure Freedom: Prognosis for New-Onset Epilepsy

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