Transcript Dr. Tsao`s PowerPoint slides

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
Age-specific incidence of epilepsy by gender in Rochester, Minnesota
Hauser WA et al. Epilepsia. 1993;34:453
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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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SANAD Trial:
Prognosis for New-Onset Epilepsy

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.
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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Seizure Freedom:
Prognosis for New-Onset Epilepsy

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
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