The National Institute for Health and Clinical Excellence (NICE) has updated its advice to doctors on the drugs which they should prescribe for patients who have epilepsy.
The guideline has been revised to fully incorporate the newer antiepileptic drugs (AEDs) which have emerged in UK clinical practice since NICE published its original guidance in 2004, says the Institute.
These newer drugs include gabapentin (Pfizer's Neurontin), lamotrigine (GlaxoSmithKline's Lamictal), levetiracetam (UCB's Keppra), oxcarbazepine (Novartis' Trileptal), tiagabine (Cephalon's Gabitril), topiramate (Johnson & Johnson's Topamax) and vigabatrin (Lundback's Sabril).
"Since we published our original clinical guidance eight years ago, the number of AEDs available in the UK has increased. This means healthcare professionals may not know whether these newer medicines bring any additional clinical benefits for their price, compared to what is already available, or when they should consider them in the treatment pathway," said Dr Fergus Macbeth, director of NICE's centre for clinical practice.
"We have updated our clinical guidance so that healthcare professionals can be sure that they are prescribing the most clinically and cost-effective treatments for their patients," he added.
The updated guidance specifies the different drug options that doctors should prescribe for their patients, both according to their type of seizure (i.e., when a diagnosis has not yet been confirmed) and according to the epilepsy syndrome. The new recommendations include:
- when possible, choose which AED to offer on the basis of the presenting epilepsy syndrome. If this is not clear at presentation, base the decision on the presenting seizure type(s);
- when prescribing sodium valproate (Sanofi's Depakine) to women and girls of present and future childbearing potential, discuss the possible risk of malformation and neuro-developmental impairments in an unborn child, particularly with high doses of the AED or when using as part of polytherapy;
- only prescribe buccal midazolam (ViroPharma's Buccolam) or rectal diazepam for use in the community for children, young people and adults who have had a previous episode of prolonged or serial convulse seizures; and
- administer buccal midazolam as first-line treatment in children, young people and adults with prolonged or repeated seizures in the community. Administer rectal diazepam if preferred, or if buccal midazolam is not available. If intravenous access is already established and resuscitation facilities are available, administer intravenous lorazepam.
"Although many people who have epilepsy are able to have their seizures controlled with medication, it can take a little time to find the right treatment before a satisfactory outcome can be reached," said Professor Helen Cross, clinical adviser to the independent group of experts which developed the guidance on NICE's behalf.
"The update to the guidance outlines how and when doctors should consider treatment for different types of epilepsy, taking into consideration the newer anti-epileptic drugs alongside the most established medicines. We hope that this will enable doctors to continue to provide the best possible care for individuals with epilepsy," said Prof Cross.
- Epilepsy is estimated to affect between 260,000 and 416,000 people in England and Wales. Two-thirds of people with active epilepsy can effectively control their seizures with an AED, says NICE.