Hostname: page-component-78c5997874-t5tsf Total loading time: 0 Render date: 2024-11-05T04:29:05.523Z Has data issue: false hasContentIssue false
  • English
  • Français

Monotherapy versus Polytherapy in Epilepsy: a Framework for Patient Management

Published online by Cambridge University Press:  18 September 2015

J.H. Schneiderman
J.H. Schneiderman*
Affiliation:
Division of Neurology and Department of Physiology, University of Toronto and Wellesley Hospital, Toronto
*
Room 1116 E.K. Jones Building, Wellesley Hospital, 160 Wellesley Street, E., Toronto, Ontario, Canada M4Y 1J3
Rights & Permissions [Opens in a new window]

Abstract:

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.

The long-standing debate between proponents of monotherapy and those of polytherapy for treatment of epilepsy has been rekindled by the recent development of several new antiepileptic drugs. The likelihood of improved seizure control on polytherapy must be weighed against the risk of increased side effects, complex drug interactions and cost. Providing maximal seizure control while avoiding overtreatment is a challenge which requires an ongoing critical evaluation of each patient's management. This review provides a framework for decision-making by considering issues affecting the choice between monotherapy and polytherapy in five clinical situations: 1) newly diagnosed epilepsy; 2) seizures on monotherapy; 3) seizures controlled on polytherapy; 4) not controlled on polytherapy; 5) change in medical condition.

Type
Research Article
Information
Canadian Journal of Neurological Sciences , Volume 25 , Issue S4 , November 1998 , pp. S9 - S13
Copyright
Copyright © Canadian Neurological Sciences Federation 1998

References

REFERENCES

1.Coll Grp Study of Epilepsy. Prognosis of epilepsy in newly referred patients: a multicentre prospective study of the effects of monotherapy on the long- term course of epilepsy. Epilepsia 1992; 33: 45–51.CrossRefGoogle Scholar
2.Heller, AJ, Chesterman, P, Elwes, RDC, et al. Phenobarbitone, phenytoin, carbamazepine, or sodium valproate for newly diagnosed adult epilepsy: a randomized comparative monotherapy trial. J Neurol Neurosurg Psychiatry 1995; 58: 44–50.CrossRefGoogle ScholarPubMed
3.De Silva, M, MacArdle, B, McGowan, M, et al. Randomised comparative monotherapy trial of phenobarbitone, phenytoin, carbamazepine, or sodium valproate for newly diagnosed childhood epilepsy. Lancet 1996; 347: 709–713.CrossRefGoogle ScholarPubMed
4.Mattson, RH, Cramer, JA, Collins, JF, et al. Comparison of carbamazepine, phenobarbital, phenytoin, and primidone in partial and secondarily generalized tonic-clonic seizures. N Engl J Med 1985; 313: 145–151.CrossRefGoogle ScholarPubMed
5.Coll Grp Study of Epilepsy. Prognosis of epilepsy in newly referred patients: a multicenter prospective study. Epilepsia 1988; 29: 236–243.CrossRefGoogle Scholar
6.Mattson, RH, Cramer, JA, Collins, JF, V.A. Epilepsy Coop. A comparison of valproate with carbamazepine for the treatment of complex partial seizures and secondarily generalized tonicclonic seizures in adults. N Engl J Med 1992; 327: 765–771.CrossRefGoogle ScholarPubMed
7.Brodie, MJ, Yuen, AWC. Lamotrigine substitution study: evidence for synergism with sodium valproate? Epilepsy Res 1997; 26: 423–432.CrossRefGoogle ScholarPubMed
8.Reynolds, EH, Shorvon, S. Monotherapy or polytherapy in epilepsy. Epilepsia 1981; 22: 1–10.CrossRefGoogle ScholarPubMed
9.Brodie, MJ, Richens, A, Yuen, AWC. Double-blind comparison of lamotrigine and carbamazepine in newly diagnosed epilepsy. Lancet 1995; 345: 476–479.CrossRefGoogle ScholarPubMed
10.Reunanen, M, Dam, M, Yuen, AWC. A randomized open multicentre comparative trial of lamotrigine and carbamazepine as monotherapy in patients with newly diagnosed or recurrent epilepsy. Epilepsy Res 1996; 23: 149–155.CrossRefGoogle ScholarPubMed
11.Kälviäinen, R, Äikiä, M, Saukkonen, AM, Mervaala, E, Riekkinen, PJ Sr., Vigabatrin vs. carbamazepine monotherapy in patients with newly diagnosed epilepsy — a randomized, controlled study. Arch Neurol 1995; 52: 989–996.CrossRefGoogle ScholarPubMed
12.Tanganelli, P, Regesta, G.Vigabatrin vs. carbamazepine monotherapy in newly diagnosed focal epilepsy: a randomized response conditional cross-over study. Epilepsy Res 1996; 25: 257–262.CrossRefGoogle ScholarPubMed
13.Chadwick, D, Anhut, H, Murray, G, et al. Int.Gabapentin monotherapy study group. Gabapentin (GBP; Neurontin) monotherapy in patients with newly-diagnosed epilepsy: results of a double-blind fixed dose study comparing three doses of gabapentin and openlabel carbamazepine. Epilepsia 1997; 38: 34.Google Scholar
14.Murray, G, Anhut, H, Greiner, M, et al. Int.Gabapentin monotherapy study group. Gabapentin (Neurontin) monotherapy: results of a multicentre study comparing gabapentin and carbamazepine in patients with newly diagnosed partial seizures. Epilepsia 1997; 38: 205.Google Scholar
15.Sachdeo, RC, Reife, RA, Lim, P, Pledger, G. Topiramate monotherapy for partial onset seizures. Epilepsia 1997; 38: 294–300.CrossRefGoogle ScholarPubMed
16.Canadian Clobazam Study Group for Childhood Epilepsy. Monotherapy clobazam vs. carbamazepine vs. phenytoin in childhood epilepsy: a double blind randomized trial with 220 Canadian children. Can J Neurol Sci 1996; 23: S18.Google Scholar
17.Lapovilla, G, Gatti, A, Veggiotti, PA. Lamotrigine monotherapy in the treatment of absence seizures in children. Epilepsia 1997; 38: 95.Google Scholar
18.MRC Antiepil Drug Withdrl Stdy Grp. Prognostic index for recurrence of seizures after remission of epilepsy. Br Med J 1993; 306: 1374–1378.CrossRefGoogle Scholar
19.Dooley, J, Gordon, K, Camfield, P, Camfield, C, Smith, E. Discontinuation of anticonvulsant therapy in children free of seizures for 1 year: a prospective study. Neurology 1996; 46: 969–974.CrossRefGoogle ScholarPubMed
20.Leppik, IE. Compliance during treatment of epilepsy. Epilepsia 1988;29(Supp 2):S79-S84.CrossRefGoogle ScholarPubMed
21.Stanaway, L, Lambie, DG, Johnson, RH. Noncompliance with anticonvulsant therapy as a cause for seizures. N Z Med J 1985; 98: 150–152.Google ScholarPubMed
22.Schmidt, D, Richter, K. Alternative single anticonvulsant drug therapy for refractory epilepsy. Ann Neurol 1986; 19: 85–87.CrossRefGoogle ScholarPubMed
23.Schmidt, D, Gram, L. Monotherapy versus polytherapy in epilepsy. CNS Drugs 1995; 3: 194–208.Google Scholar
24.Prasad, AN, Stafstrom, CF, Holmes, GL. Alternative epilepsy therapies: the ketogenic diet, immunoglobulins, and steroids. Epilepsia 1996; 37: S81-S95.CrossRefGoogle ScholarPubMed
25.Deckers, CLP, Hekster, YA, Keyser, A, , H, Renier, WO. Reappraisal of polytherapy in epilepsy: a critical review of drug load and adverse effects. Epilepsia 1997; 38: 570–575.CrossRefGoogle ScholarPubMed
26.Kaneko, S, Otani, K, Kondo, T, et al. Malformation in infants of mothers with epilepsy receiving antiepileptic drugs. Neurology 1992;42(Suppl. 5): 68–74.Google ScholarPubMed
27.Dravet, C, Julian, C, Legras, C, et al. Epilepsy, antiepileptic drugs, and malformations in children of women with epilepsy: a French prospective cohort study. Neurology 1992; 42 (Suppl. 5): 75–82.Google ScholarPubMed
28.Lindhout, D. Pharmacogenetics and drug interactions: role in antiepileptic- drug-induced teratogenesis. Neurology 1992; 42 Suppl. 5: 43–47.Google ScholarPubMed
29.Samren, EB, Van Duijn, CM, Koch, S, et al. Maternal use of antiepileptic drugs and the risk of major congenital malformations: a joint European prospective study of human teratogenesis associated with maternal epilepsy. Epilepsia 1997; 38: 981–990.CrossRefGoogle ScholarPubMed
30.Eriksson, AS, Hoppu, K, Nergardh, A, Boreus, L. Pharmacokinetic interactions between lamotrigine and other antiepileptic drugs in children with intractable epilepsy. Epilepsia 1996; 37: 769–-773.CrossRefGoogle ScholarPubMed
31.Johannessen, SI. Pharmacokinetics and interaction profile of topiramate: review and comparison with other newer antiepileptic drugs. Epilepsia 1997; 38: S18-S23.CrossRefGoogle ScholarPubMed
32.Anderson, GD, Yau, MK, Gidal, BE, et al. Bidirectional interaction of valproate and lamotrigine in healthy subjects. Clin Pharmacol Ther 1996; 60: 145–156.CrossRefGoogle ScholarPubMed
33.Tomson, T, Lindbom, U, Ekqvist, B, Sundqvist, A. Disposition of carbamazepine and phenytoin in pregnancy. Epilepsia 1994; 35: 131–135.CrossRefGoogle ScholarPubMed
34.Tomson, T, Lindbom, U, Ekqvist, B, Sundqvist, A. Epilepsy and pregnancy: a prospective study of seizure control in relation to free and total plasma concentrations of carbamazepine and phenytoin. Epilepsia 1994; 35: 122–130.CrossRefGoogle ScholarPubMed
35.Yerby, MS, Devinsky, O. Epilepsy and pregnancy. Adv Neurol 1994; 64: 45–63.Google ScholarPubMed
36.Bourgeois, BFD. Important pharmacokinetic properties of antiepileptic drugs. Epilepsia 1995; 36: S1-S7.CrossRefGoogle ScholarPubMed
37.Elwes, RDC, Binnie, CD. Clinical pharmacokinetics of newer antiepileptic drugs — lamotrigine, vigabatrin, gabapentin and oxcarbazepine. Clin Pharmacokinet 1996; 30: 403–415.CrossRefGoogle ScholarPubMed
38.Perucca, E. Pharmacokinet profile of topiramate in comparison with other new antiepileptic drugs. Epilepsia 1996; 37: S8-S13.CrossRefGoogle Scholar
39.Battino, D, Estienne, M, Avanzini, G. Clinical pharmacokinetics of antiepileptic drugs in paediatric patients. 2. Phenytoin, carbamazepine, sulthiame, lamotrigine, vigabatrin, oxcarbazepine and felbamate. Clin Pharmacokinet 1995; 29: 341–369.CrossRefGoogle Scholar
40.Battino, D, Estienne, M, Avanzini, G. Clinical pharmacokinetics of antiepileptic drugs in paediatric patients. 1. Phenobarbital, primidone, valproic acid, ethosuximide and mesuximide. Clin Pharmacokinet 1995; 29: 257–286.CrossRefGoogle Scholar
41.Boggs, JG. Seizures in medically complex patients. Epilepsia 1997; 38: S55-S59.CrossRefGoogle ScholarPubMed
42.Graves, NM. Neuropharmacology and drug interactions in clinical practice. Epilepsia 1995; 36: S27-S33CrossRefGoogle ScholarPubMed
43.Cloyd, J. Pharmacokinetic pitfalls of present antiepileptic medications. Epilepsia 1991; 32 (Suppl 5): S53-S65.Google ScholarPubMed
44.Brodie, MJ. Drug interactions in epilepsy. Epilepsia 1992; 33 (Suppl. 1): S13-S22.CrossRefGoogle ScholarPubMed
45.Willmore, LI. The effect of age on pharmacokinetics of antiepileptic drugs. Epilepsia 1995; 36: S14-S21.CrossRefGoogle ScholarPubMed