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Epilepsy Guidelines Shun 'One Size Fits All' Therapy

Seek one-drug treatment, special care for women and elderly

TUESDAY, Nov. 27, 2001 (HealthDayNews) -- Doctors can best treat epileptics by prescribing just one drug to control seizures and resorting to combination therapies only when a single-drug regimen fails, according to new guidelines that also call for specialized epilepsy treatment for women and the elderly.

A host of new anti-epileptic drugs have made treatment decisions a lot more complicated for doctors who may be more familiar with older medications, say the guideline authors. Advances in treatment of epilepsy and recognition of the special needs of women and older Americans create the need for "optimal treatment strategies, based on seizure type and individual needs."

"There has been an explosion of treatment options in the past 10 years," says Dr. Martha Morrell, director of the Columbia Comprehensive Epilepsy Center of New York-Presbyterian Hospital in New York City. "Our goal with these new guidelines is seizure control with no medication side effects and access to usual life experience."

Morrell and her colleagues surveyed 45 top epilepsy specialists around the country to find out what's considered the cutting edge in treatment. "This is the first time that there has been any expert opinion put forward to develop treatment guidelines. Currently, the American Academy of Neurology is working on evidence-based guidelines, but we felt the need to fill in the gap in the meantime," Morrell explains.

Evidence-based guidelines have limitations, Morrell adds. "You can only make statements or propose guidelines where there is clear evidence. For the newer anti-epileptic drugs we don't necessarily have all the medical trials available to tell us how to best use these medications in the real world, and that's why we turned to expert opinion."

Primary among the guidelines is testing single-drug therapies for the suppression of seizures, rather than resorting to combinations of drugs.

"Monotherapy is one that has been embraced by epilepsy specialists for about a decade," Morrell says. "But monotherapy is still not necessarily appreciated by most of the general physicians taking care of most of the people with epilepsy."

According to the Epilepsy Foundation, the vast majority of epileptics are treated by general physicians or neurologists, who may treat only five or six patients a year, and may only come across one or two new cases every two to three years.

Epilepsy is the third most common neurological disorder in the United States, affecting 2.3 million Americans, with 60,000 new cases diagnosed every year, according to the Epilepsy Foundation. And of the 26 drugs now used for the treatment of epilepsy, eight were introduced in the past 10 years.

Experts now say that epilepsy cannot be treated with a "one size fits all" approach. Recent studies have shown that many anti-epileptic drugs wreak havoc with a woman's reproductive system or worsen the thinking ability of older patients whose epilepsy may be a result of stroke or Alzheimer's disease.

"Many of the older anti-seizure medications cause reproductive health disruption," Morrell explains. "They can change hormones by increasing breakdown of sex steroid hormones and, in some cases -- like Valproate -- increase the production of the male-type hormone androgen, causing facial hair growth, male-pattern baldness and obesity. We also know that these women are more likely to have menstrual cycles in which they do not ovulate."

Anti-seizure medications have also been associated with osteoporosis, in both men and women, Morrell adds.

For people over the age of 65, the danger is the interaction of anti-seizure medication with drugs taken for stroke or Alzheimer's.

"The newer medications seem to be better tolerated and seem to have less drug/drug interactions, which is important for the elderly who are taking other medications," Morrell says. "The older anti-seizure medications also cause side effects in the elderly like dizziness, fatigue, cognitive slowing, and coordination problems."

Morrell says doctors need to pay attention to the type of seizure when prescribing drugs. "For instance, experts say that an older-type drug like carbamazepine is considered the drug of first choice for an adult with partial seizure," she says, adding that lamotrigine "is the choice for partial seizures in women or in an elderly individual."

The consensus guidelines were announced today at a press conference at Columbia Presbyterian Medical Center and will be published in the November/December issue of Epilepsy and Behavior.

"Epilepsy is a complex neurological disease, and it's not so easy to treat, and the best outcome will be achieved by considering all of the treatment options," Morrell says. "We hope that these guidelines will help physicians direct towards particular medications that are likely to be a good choice for an individual patients -- no more 'one size fits all."

These guidelines are not set in stone, adds Dr. Gregory L. Barkley, medical director of the Henry Ford Comprehensive Epilepsy Program in Detroit. "These guidelines were a snapshot in time that reflected current knowledge in October of 2000, which was only six months after the introduction of three new anti-convulsant drugs. And while epilepsy specialists had some exposure to these new drugs, the general neurology community may have had some very limited exposure, and the primary care community probably had none."

"So these guidelines will certainly continue to evolve," Barkley says. "I'm sure some of the responses [on the treatment survey] to some of these newer drugs would be different today because some of these newer drugs are emerging as preferred drugs in certain circumstances."

What To Do

Talk to your doctor if you have this illness, and find out if she is familiar with the new guidelines and the newer drugs.

For more on epilepsy treatments, see the Epilepsy Foundation or the World Health Organization.

SOURCES: Interviews with Martha Morrell, M.D., professor of neurology, and director, Columbia Comprehensive Epilepsy Center of New York-Presbyterian Hospital, New York; Gregory L. Barkley, M.D., medical director, Henry Ford Comprehensive Epilepsy Program, Detroit; New York-Presbyterian Hospital news teleconference and press release
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