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Overall outcomes in new epilepsy cases not improving
Overall patient outcomes in those with newly diagnosed epilepsy have not improved over the past 30 years despite many new antiepileptic drugs that have different mechanisms of action, according to findings recently published in JAMA Neurology.
“Newer [antiepileptic drugs] are generally effective, and many have favorable safety profiles, but all have been reported to have efficacy similar to the established [antiepileptic drugs] when used as monotherapy or adjunctive treatment. Whether their availability has improved the overall prognosis of epilepsy therefore remains controversial,” Zhibin Chen, PhD, of the department of medicine at the University of Melbourne in Australia and colleagues wrote.
Researchers performed a longitudinal observational cohort study of 1,795 patients (mean age, 33 years) newly treated for epilepsy with antiepileptic drugs at an infirmary in Scotland between July 1, 1982, and Oct. 31, 2012. Slightly more than 53% of the participants were male.
Chen and colleagues found that at the end of at least 2 years or the study participant’s death — whichever came first — 63.7% of the patients did not have a seizure in the previous year or longer. Of those, 89.9% reached seizure control with the first or second antiepileptic drug regimen and 86.8% took a single drug for their epilepsy.
In addition, researchers wrote that of the original 1,795 patients, 50.5% did not have a seizure for 1 year or longer with their first antiepileptic drug regimen. If this dose did not work, the second regimen allowed for an additional 11.6% likelihood of seizure freedom and the third regimen allowed for a 4.4% likelihood of seizure freedom. Only 2.12% of patients achieved “optimal seizure control” with additional antiepileptic drugs. Epilepsy that was not successfully controlled with the first antiepileptic drug regimen was also less likely to respond to each medication regimen that followed (OR = 1.73; 95% CI, 1.56-1.91).
“The present study confirmed our previous observations that the likelihood of becoming seizure-free decreases with each unsuccessful [antiepileptic drugs] regimen,” Chen and colleagues wrote.
“A paradigm shift in treatment and research strategies is needed to improve the long-term outcomes of newly diagnosed epilepsy. Patients with drug-resistant epilepsy should be considered early for nonpharmacological therapies, such as resective surgery and brain stimulation techniques. ... Future research should focus on novel treatments that can modify the development or progression of epilepsy, ideally guided by biomarkers,” they added”
In a related editorial, W. Allen Hauser, MD, of the College of Physicians and Surgeons at Columbia University, indicated that some of Chen and colleagues’ findings are “not new and should not be surprising.”
“In 1881, pioneering neurologist Sir William Gowers reported that he could not control seizures in 36% of the patients to whom he prescribed bromide compounds. It seems that we might not have improved our initial management results for a much longer period than the 30 years covered in the current study. While biologically unlikely, it is possible that a two-thirds proportion represents a ceiling for the initial control of epilepsy.”
Hauser joined Chen and colleagues in concluding that new strategies in many phases of the fight against epilepsy need to occur. – by Janel Miller
Disclosure: Chen reports no relevant financial disclosures. Hauser reports being a member of the Sudden Unexpected Death in Epilepsy monitoring committee of Neuropace and a member of the editorial boards of Acta Neurologica Scandinavia, Epilepsy Research, and Neuroepidemiology. Please see the study for all other authors’ relevant financial disclosures.