Context

Treatment alternatives

Zonisamide is indicated for the adjunctive treatment of partial seizures with or without secondary generalisation. The NICE clinical guideline on epilepsy advises that adjunctive treatment of partial (focal) seizures in children, young people and adults should normally be with carbamazepine, clobazam, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, sodium valproate or topiramate. If this is ineffective or not tolerated, advice should be sought from a tertiary epilepsy specialist. Anti-epileptic drugs that may be considered by the tertiary epilepsy specialist at this stage in the care pathway are eslicarbazepine acetate, lacosamide, phenobarbital, phenytoin, pregabalin, tiagabine, vigabatrin and zonisamide.

Prescribers should be aware that not all the drugs mentioned above currently have a UK marketing authorisation for use for the particular indication or population mentioned (for example, depending on the age of the person). In line with the guidance from the General Medical Council (GMC), it is the responsibility of the prescriber to determine the clinical need of the patient and the suitability of using drugs outside their authorised indications. The table below details the costs of treatment alternatives that are licensed for use in children or young people and includes those recommended as first- or second-line adjunctive treatments in the NICE clinical guideline on epilepsy.

Costs of treatment alternatives

Druga

Usual maintenance dose for children and young people b

28-day cost excluding VAT

Carbamazepinec

5–18 years: 400–1200 mg daily in several divided doses depending on age

Tegretol tablets: £2.55 to £7.53d

Clobazame

6 years and over: 0.3–1.0 mg/kg daily

Depends on child's weight; for a 32 kg child: £2.34 to £7.03 (Frisium tablets)d, £2.51 to £7.53 (generic tablets)f

Gabapenting

6–11 years: 25–35 mg/kg daily in 3 divided doses

Depends on child's weight; for a 32 kg child: £4.01 to £4.13 (generic capsules)f

12 years and over: 900–3600 mg daily in 3 divided doses

£3.77 to £12.02 (generic capsules)f

Lacosamideg

Not recommended for use in people less than 16 years

For young people aged 16–18 years: 100–200 mg twice daily

£86.50 to £144.16 (tablets)d

Lamotriginee

2–12 years: 1–15 mg/kg daily depending on concomitant medications, in 1 or 2 divided doses

Depends on child's weight; for a 32 kg child: £9.81 to £97.79 (Lamictal tablets)d, £0.75 to £3.77 (generic tablets)f

13 years and over: 100–400 mg daily depending on concomitant medications, in 1 or 2 divided doses

£28.77 to £97.79 (Lamictal tablets)d

£1.24 to £3.77(generic tablets)f

Levetiracetamg

6–17 years weighing less than 50 kg: 10–30 mg/kg twice daily

Depends on child's weight; for a 32 kg child: £1.80 to £4.72 (generic tablets)f

12–17 years weighing 50 kg or more: 500–1500 mg twice daily

£2.37 to £7.52 (generic tablets)f

Oxcarbazepinee

6 years and over: approximately 30 mg/kg daily in 2 divided doses

Depends on child's weight; for a 32 kg child: £34.27 (Trileptal tablets)d, £44.44 (generic tablets)f

Perampanele

12 years and over: 4–8 mg once daily

£140 (Fycompa tablets, no generic available)d

Phenobarbitalc

Children: 2.5–8 mg/kg daily

For a 32 kg child: £2.73 to £26.28 (no branded product available)f

Adults: 60–180 mg once daily

£6.57 to £19.71 (no branded product available)f

Phenytoin sodiumc

Infants and children: 4–8 mg/kg daily

Depends on child's weight; for a 32 kg child: £47.40 to £76.48 (Flynn hard capsules)f

Adults: 200–500 mg daily in single or divided doses

£45.00 to £112.50 (Flynn hard capsules)f

Sodium valproatee

Child or young person weighing over 20 kg: initially 400 mg daily, usual range 20–30 mg/kg daily in 2 divided doses

Depends on child's weight; for a 32 kg child: £6.47 to £10.78 (Epilim gastro-resistant tablets)d, £3.47 to £4.52 (generic gastro-resistant tablets)f

Adults: 1000–2000 mg daily in 2 divided doses

£10.78 to £21.56 (Epilim gastro-resistant tablets)d £4.52 to £9.04 (generic gastro-resistant tablets)f

Tiagabineg

12 years and over: 15–45 mg daily depending on concomitant medications, in 2 or 3 divided doses

£43.71 to £131.15 (Gabitril tablets, no generic available)d

Topiramatee

2 years and over: 5–9 mg/kg daily in 2 divided doses

Depends on child's weight; for a 32 kg child: £54.01 to £88.73 (Topamax tablets)d

£7.76 to £8.71 (generic tablets)f

Vigabatring

Child or young person weighing 10 kg and over: 0.5–3 g daily in 1 to 2 divided doses depending on weight

Tablets: £10.36 to £62.18 (Sabril tablets, no generic available)f

Zonisamidee

Child or young person 6 years and over weighing 20–55 kg: 6–8 mg/kg once daily

Depends on child's weight; for a 32 kg child: £62.72 to £86.24 (Zonegran capsules, no generic available)f

Child or young person 6 years and over weighing more than 55 kg: 300–500 mg once daily

£94.08 to £156.80 (Zonegran capsules, no generic available)f

a For a number of antiepileptic drugs, several different formulations are available: only one has been selected here for reasons of clarity. If the MHRA has advised prescribers to ensure that their patient is maintained on a specific manufacturer's product, the cost for the originator product has been given as an example where possible; other manufacturer's products may also be available. If the MHRA has advised that the need for continued supply of a particular manufacturer's product should be based on clinical judgement and consultation with patient and/or carer, the cost for the originator product and the generic (Drug Tariff) price has been given. For other products the Drug Tariff price has been given.

b Doses taken from the relevant summary of product characteristics or the British National Formulary for Children. The doses shown do not represent the full range that can be used and they do not imply therapeutic equivalence.

c The MHRA has advised prescribers to ensure that their patient is maintained on a specific manufacturer's product.

d Costs taken from MIMS February 2014.

e The MHRA has advised that the need for continued supply of a particular manufacturer's product should be based on clinical judgement and consultation with patient and/or carer, taking into account factors such as seizure frequency and treatment history.

f Costs taken from Drug Tariff February 2014.

g The MHRA has advised that it is usually unnecessary to ensure that patients are maintained on a specific manufacturer's product unless there are specific reasons such as patient anxiety and risk of confusion or dosing errors.