From the Guidelines
Focal epilepsy should be managed with antiepileptic drugs (AEDs) as the first line of treatment, with surgery considered for drug-resistant cases, particularly when seizures originate from a well-defined, removable brain region, as supported by the European Association of Nuclear Medicine (EANM) guidelines 1.
Treatment Approach
The treatment approach for focal epilepsy typically involves:
- Antiepileptic drugs (AEDs) such as carbamazepine (200-1200 mg/day), lamotrigine (100-400 mg/day), levetiracetam (1000-3000 mg/day), or lacosamide (200-400 mg/day) as first-line therapy 1
- Starting with a single AED at a low dose, gradually increasing until seizures are controlled or side effects occur
- Switching to another monotherapy or adding a second drug if the first medication fails
- Consistent medication intake at scheduled times to maintain therapeutic blood levels
- Keeping a seizure diary to track frequency, duration, and potential triggers
- Lifestyle modifications, including regular sleep patterns, stress management, limiting alcohol, and avoiding seizure triggers
Diagnostic Tools
Diagnostic tools for focal epilepsy include:
- Scalp video/electroencephalography (EEG) telemetry
- Structural and functional magnetic resonance imaging (MRI)
- Molecular neuroimaging using different radiopharmaceuticals with single-photon emission computed tomography (SPECT) and positron emission tomography (PET) 1
- Intracranial EEG electrodes for additional value depending on the epilepsy type
Surgery Consideration
Surgery may be considered for drug-resistant cases, particularly when seizures originate from a well-defined, removable brain region, with approximately 65% of patients becoming seizure-free 1. The EANM guidelines aim to assist in understanding the role and challenges of radiotracer imaging for epilepsy and provide practical information for performing different molecular imaging procedures for epilepsy 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. The FDA-approved indication for levetiracetam includes focal epilepsy, also known as partial onset seizures.
- Key points:
- Levetiracetam is used as an adjunctive treatment for partial onset seizures.
- The recommended dose for adults is 1000-3000 mg/day, and for pediatric patients, it is 20-60 mg/kg/day.
- Levetiracetam can be used in patients 4 years of age and older with epilepsy 2.
The effectiveness of topiramate as an adjunctive treatment for adults with partial onset seizures was established in six multicenter, randomized, double-blind, placebo controlled trials Topiramate is also indicated for focal epilepsy, or partial onset seizures.
- Main considerations:
- Topiramate can be used as an adjunctive treatment for partial onset seizures in adults and pediatric patients.
- The target dosage of topiramate is 400 mg/day for adults, and 6 mg/kg per day for pediatric patients.
- Topiramate has been shown to be effective in reducing the frequency of partial onset seizures 3.
From the Research
Definition and Prevalence of Focal Epilepsy
- Focal epilepsy is the most prevalent epilepsy in adults, accounting for a significant portion of epilepsy cases 4.
- It is characterized by seizures that originate from a specific region of the brain.
Treatment of Focal Epilepsy
- The primary goal of epilepsy treatment is to eliminate seizures while minimizing adverse effects of antiseizure drugs (ASDs) 5.
- Antiepileptic drug (AED) prescription in patients with new-onset focal epilepsy is often challenging, and the choice of AED depends on patient-specific and AED-specific variables 4.
- Monotherapy is the initial strategy, and failure to monotherapy can be due to lack of efficacy, severe adverse events, or a hypersensitivity reaction 4.
- In patients who fail up to three monotherapy trials, duotherapy with drugs having different primary mechanisms of action should be the next step 4.
Antiseizure Medications for Focal Epilepsy
- There are 26 US Food and Drug Administration-approved medications for epilepsy, of which 24 have similar antiseizure efficacy for focal epilepsy 5.
- Oxcarbazepine and lamotrigine are first-line therapy for focal epilepsy, while levetiracetam can be also considered if there is no history of psychiatric disorder 5.
- Levetiracetam, lamotrigine, oxcarbazepine, sulthiame, and topiramate are newer AEDs that should be considered for monotherapy of focal epilepsy due to their efficacy and tolerability profiles 6.
Combination Therapy for Focal Epilepsy
- There is no definite proven or accepted strategy in the management of patients with focal epilepsy uncontrolled by the first anti-seizure medication 7.
- Clinical studies have shown that levetiracetam can be favorably combined with the sodium channel blockers lacosamide and lamotrigine 7.
- Lamotrigine is particularly effective when associated with valproate and possibly with levetiracetam and topiramate 7.
Efficacy and Tolerability of Antiepileptic Drugs
- A systematic review and network meta-analyses found that clobazam, levetiracetam, lamotrigine, oxcarbazepine, sulthiame, topiramate, and valproate had the best efficacy profiles for monotherapy of focal epilepsy 6.
- Lamotrigine had the best safety profile and an 81% probability of being the best for the tolerability outcome of patient withdrawals from the study due to intolerable adverse reactions 6.