What are the treatments for epilepsy (seizure disorder)?

From the Guidelines

Seizures are best treated with antiepileptic drugs (AEDs) such as levetiracetam, fosphenytoin, or valproate, which have been shown to result in cessation of seizures in approximately half of all patients with benzodiazepine-resistant status epilepticus, as evidenced by the most recent study 1. The primary goal of treatment is to reduce morbidity and mortality by stopping the seizure as quickly as possible.

• First-line medications for seizure management include levetiracetam (Keppra, 500-1500mg twice daily), which has been recommended as a second-line agent for seizures refractory to benzodiazepines 1.
• For emergency seizure management, benzodiazepines like lorazepam (Ativan, 2-4mg IV) or diazepam (Valium, 5-10mg IV) are administered, but if seizures are refractory to these medications, a second-line agent such as fosphenytoin, levetiracetam, or valproate may be used with similar efficacy 1.
• Treatment usually begins with a single medication at a low dose, gradually increasing until seizures are controlled or side effects become problematic.
• If monotherapy fails, a second medication may be added or substituted, and most patients require lifelong treatment, though some may eventually taper off medications under medical supervision.
• Beyond medications, treatment may include surgery for drug-resistant cases, vagus nerve stimulation, or dietary approaches like the ketogenic diet, which work by stabilizing neuronal membranes, enhancing inhibitory neurotransmission, or reducing excitatory neurotransmission to prevent the abnormal electrical activity that causes seizures.
• Regular monitoring of medication levels and potential side effects is essential for optimal management, as the benefits of early treatment and cessation of status epilepticus include a reduction in morbidity and mortality, with limited harms apart from the potential for an adverse drug reaction 1.

From the FDA Drug Label

Levetiracetam is indicated as adjunctive treatment of partial onset seizures in adults and children 4 years of age and older with epilepsy. Levetiracetam is indicated as adjunctive therapy in the treatment of myoclonic seizures in adults and adolescents 12 years of age and older with juvenile myoclonic epilepsy Levetiracetam is indicated as adjunctive therapy in the treatment of primary generalized tonicoclonic seizures in adults and children 6 years of age and older with idiopathic generalized epilepsy. Topiramate Tablets are indicated as initial monotherapy in patients 10 years of age and older with partial onset or primary generalized tonic-clonic seizures. Topiramate Tablets are indicated as adjunctive therapy for adults and pediatric patients ages 2 to 16 years with partial onset seizures, or primary generalized tonic-clonic seizures, and in patients 2 years of age and older with seizures associated with Lennox-Gastaut syndrome.

The treatments for epilepsy (seizure disorder) include:

• Levetiracetam (PO): as adjunctive treatment for partial onset seizures, myoclonic seizures, and primary generalized tonic-clonic seizures
• Topiramate (PO): as initial monotherapy for partial onset or primary generalized tonic-clonic seizures, and as adjunctive therapy for partial onset seizures, primary generalized tonic-clonic seizures, and seizures associated with Lennox-Gastaut syndrome 2, 3 Key points:
• Levetiracetam and topiramate are used to treat various types of seizures in adults and children
• The dosage and administration of these medications vary depending on the type of seizure, age, and weight of the patient
• It is essential to follow the recommended dosage and administration guidelines to ensure effective treatment and minimize adverse events 2

From the Research

Treatments for Epilepsy

The primary goal of epilepsy treatment is to eliminate seizures while minimizing adverse effects of antiseizure drugs (ASDs) 4. There are several treatments available for epilepsy, including:

• Antiseizure medications: There are 26 US Food and Drug Administration-approved medications for epilepsy, of which 24 have similar antiseizure efficacy for focal epilepsy and 9 have similar efficacy for generalized epilepsy 4.
• First-line therapies: For focal epilepsy, oxcarbazepine and lamotrigine are first-line therapy, while levetiracetam can be also considered if there is no history of psychiatric disorder 4.
• Treatment for generalized epilepsy: The selection of the ASD is based on the type of epilepsy syndrome and the patient's sex, age, and psychiatric history 4.
• Second-generation antiepileptic drugs: These include levetiracetam, gabapentin, topiramate, lamotrigine, zonisamide, oxcarbazepine, vigabatrin, pregabalin, rufinamide, tiagabine, lacosamide, and felbamate 5.
• Injectable AEDs: These include levetiracetam, lacosamide, fosphenytoin, lorazepam, and valproic acid 5.

Factors to Consider When Selecting a Treatment

When selecting a treatment for epilepsy, several factors should be considered, including:

• Seizure type and epilepsy syndrome: The choice of medication should be based on its efficacy against the seizure type or types or epilepsy syndrome being treated 6.
• Patient's age and sex: The selection of the ASD should consider the patient's age and sex, as well as comorbidities and potential drug interactions 4.
• Comorbidities: The presence of comorbidities, such as mood, anxiety, and attention deficit disorders, should be considered when selecting a treatment 4.
• Potential drug interactions: The potential for drug interactions should be considered when selecting a treatment, particularly for patients taking multiple medications 4.

Efficacy of Different Treatments

The efficacy of different treatments for epilepsy has been studied in several trials, including:

• The SANAD II trial, which compared the efficacy of lamotrigine, levetiracetam, and zonisamide for focal epilepsy, and valproate and levetiracetam for generalized and unclassified epilepsy 7.
• A network meta-analysis of individual participant data, which compared the efficacy of 10 AEDs for partial onset seizures and generalized onset tonic-clonic seizures 8.
• A review of second-generation antiepileptic drugs, which compared the efficacy and safety of several AEDs, including levetiracetam, gabapentin, topiramate, lamotrigine, zonisamide, oxcarbazepine, vigabatrin, pregabalin, rufinamide, tiagabine, lacosamide, and felbamate 5.