What is the initial treatment for chronic management of focal seizures?

From the Guidelines

The initial treatment for chronic management of focal seizures should involve antiepileptic drugs (AEDs), with levetiracetam being a preferred option due to its efficacy and safety profile, as supported by recent guidelines 1. When considering the treatment of focal seizures, it's essential to prioritize medications that have demonstrated high efficacy and a favorable side effect profile.

• Levetiracetam (Keppra) is often started at 500 mg twice daily and can be titrated up to 1500-3000 mg daily in divided doses.
• Other commonly used medications include carbamazepine (Tegretol), lamotrigine, oxcarbazepine, and lacosamide. Key considerations in the management of focal seizures include:
• Starting treatment with a single medication at a low dose and gradually increasing until seizures are controlled or side effects become problematic.
• Preferring monotherapy to minimize adverse effects, though some patients may require combination therapy if seizures persist.
• Regular monitoring of drug levels, liver function, and complete blood counts is important for many AEDs, as noted in the management of seizures 1. Treatment success is defined as complete seizure freedom, and medication should be continued for at least 2 years after the last seizure before considering tapering, emphasizing the importance of long-term management and monitoring in achieving optimal outcomes for patients with focal seizures.

From the FDA Drug Label

1. 3 Initiation of Monotherapy for Adults Patients not currently being treated with AEDs may have monotherapy initiated with oxcarbazepine. In these patients, initiate oxcarbazepine at a dose of 600 mg/day (given a twice-a-day); the dose should be increased by 300 mg/day every third day to a dose of 1,200 mg/day

The initial treatment for chronic management of focal seizures with oxcarbazepine is to initiate monotherapy at a dose of 600 mg/day, given twice a day, and increase the dose by 300 mg/day every third day to a dose of 1,200 mg/day 2.

• The dose may be adjusted based on patient response and tolerability.
• Patients should be observed closely during the initiation phase.

From the Research

Initial Treatment for Chronic Management of Focal Seizures

The initial treatment for chronic management of focal seizures typically involves the use of antiepileptic drugs (AEDs). Several studies have compared the efficacy of different AEDs in the treatment of focal seizures.

• A study published in 2018 3 found that lamotrigine monotherapy was more effective than phenytoin monotherapy in patients with focal epilepsy.
• Another study published in 2021 4 compared the efficacy of lamotrigine, levetiracetam, and zonisamide in patients with focal epilepsy, and found that lamotrigine was superior to both levetiracetam and zonisamide in terms of time to 12-month remission and time to treatment failure.
• A review article published in 2021 5 noted that level A evidence for initial monotherapy is available for seven drugs, including lamotrigine, levetiracetam, and zonisamide, but that there is no robust data supporting that one drug is superior to the others.

Factors Influencing Treatment Choices

When selecting an AED for the treatment of focal seizures, several factors should be considered, including:

• Efficacy: The ability of the drug to control seizures and prevent recurrence.
• Safety: The potential for adverse effects, such as drowsiness, headache, and gastrointestinal disturbances.
• Tolerability: The ability of the patient to tolerate the drug and its potential side effects.
• Pharmacoeconomic reasons: The cost of the drug and its potential impact on the patient's quality of life.
• A study published in 2006 6 noted that factors such as adverse-effect profiles, age, possibility of pregnancy, and concomitant diseases and medication should also be considered when choosing an AED.

Network Meta-Analysis of AEDs

A network meta-analysis published in 2017 7 compared the efficacy of 10 AEDs, including carbamazepine, lamotrigine, and levetiracetam, in patients with partial onset seizures and generalised onset tonic-clonic seizures.

• The analysis found that levetiracetam performed significantly better than carbamazepine and lamotrigine in terms of time to withdrawal of allocated treatment.
• The analysis also found that sodium valproate performed significantly better than carbamazepine, topiramate, and phenobarbitone in patients with generalised onset seizures.