Newer drugs for epilepsy in adults

NICE technology appraisals [TA76] Published date:

This guidance has been replaced by CG137 Epilepsy

NICE has made the following recommendations about the use of newer drugs to treat adults with epilepsy.

If the older drugs (such as sodium valproate and carbamazepine) do not stop a person from having seizures, or if the person experiences side effects, one of the newer drugs can be tried, as long as it is suitable for the type of epilepsy the person has. Lamotrigine, oxcarbazepine and topiramate can be given as the person’s only treatment for epilepsy. They can also be given with another drug when that drug on its own does not stop a person’s seizures (this is called combination therapy). Gabapentin, levetiracetam, tiagabine and vigabatrin are generally used as combination therapy with another drug.

A newer drug can also be tried if the older drugs are unsuitable for the person. This could be because there is a reason why he or she cannot take the older drugs (for example, some drugs are not suitable for people with liver disease), or because they cause unwanted effects that the person cannot tolerate. The older drugs might also be unsuitable if they affect another drug the person is taking (for example, some antiepileptic drugs make the contraceptive pill work less well).Some antiepileptic drugs are unsuitable for women with epilepsy who might become pregnant because they might harm an unborn child.

NICE recommends that people should be treated with just one antiepileptic drug where possible. If the first drug doesn’t stop a person having seizures, another can be tried. The person’s doctor will need to take special care when changing over from one drug to another.

If the person has tried several drugs and none of them stops the seizures on its own, another drug can be added. This is called adjunctive or combination therapy. If the first combination does not work, other combinations can be tried. If none of them completely stops the seizures, the person should take the single drug or combination that works best for him or her. The decision on what drug or drugs a person takes will depend on the drugs’ unwanted effects as well as how good they are at preventing his or her seizures.

Particular care is needed when deciding what drug to use for women who are pregnant or might get pregnant. When women take antiepileptic drugs during pregnancy, this can sometimes harm the baby. Many women with epilepsy need to continue taking antiepileptic drugs during pregnancy and it might be appropriate to make adjustments to a woman’s drug treatment before she becomes pregnant. Women with epilepsy who are considering starting a family should discuss this with their epilepsy specialists. There is not yet enough information to say what precise effects the newer drugs have on an unborn child. The choice of antiepileptic drug may also affect a woman’s choice of contraceptive, so this needs to be discussed as well. Specific caution is advised in the use of sodium valproate because of the risk of harm to the unborn child.

A person who has a seizure for the first time should see an epilepsy specialist as soon as possible, to find out exactly what type of epilepsy he or she has, so that the best treatment can be started.

People with epilepsy should see a doctor regularly to make sure they are taking the drug or combination of drugs that works best for them, and that they are taking it correctly.

NICE’s recommendations apply to all adults with epilepsy, including elderly people and people with learning disabilities.

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