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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)
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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
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Factors Involved in Clinical Decisions
Mulrow CD et al. Ann Intern Med. 1997;126:389
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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
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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
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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
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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/)
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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
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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
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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
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New-Onset Epilepsy in the Elderly
Hauser WA et al. Epilepsia. 1993;34:453
Age-specific incidence of epilepsy by gender in Rochester, Minnesota
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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
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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
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Cumulative Probability of Being Seizure Free
Brodie MJ et al. Neurology. 2012;78:1548
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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