Epilepsy affects approximately 65 million people worldwide. Persistent seizures are associated with a 20% to 40% risk of bodily injuries (eg, fractures, burns, concussions) over 12-month follow-up. The primary goal of epilepsy treatment is to eliminate seizures while minimizing adverse effects of antiseizure drugs (ASDs).
An epileptic seizure is defined as a sudden occurrence of transient signs and symptoms caused by abnormal and excessive or synchronous neuronal activity in the brain. Focal and generalized epilepsy are the 2 most frequent types of epilepsy; diagnosis is based on the type of seizures. There are 26 US Food and Drug Administration–approved medications for epilepsy, of which 24 have similar antiseizure efficacy for focal epilepsy and 9 have similar efficacy for generalized epilepsy. The decision to initiate an ASD should be individualized, but should be strongly considered after 2 unprovoked seizures or after 1 unprovoked seizure that occurred during sleep and/or in the presence of epileptiform activity on an electroencephalogram and/or in the presence of a structural lesion on the brain magnetic resonance imaging. The ASDs must be selected based on the seizure and epilepsy types, the epilepsy syndrome, and the adverse effects associated with the drug. For focal epilepsy, oxcarbazepine and lamotrigine are first-line therapy, while levetiracetam can be also considered if there is no history of psychiatric disorder. For generalized epilepsy, the selection of the ASD is based on the type of epilepsy syndrome and the patient’s sex, age, and psychiatric history. Seizure freedom is achieved in approximately 60% to 70% of all patients. A total of 25% to 50% of patients also experience neurologic, psychiatric, cognitive, or medical disorders, such as mood, anxiety, and attention deficit disorders and migraines. For these patients, selecting an ASD should consider the presence of these disorders and concomitant use of medications to treat them. ASDs with cytochrome P450 enzyme-inducing properties (eg, carbamazepine, phenytoin) may worsen comorbid coronary and cerebrovascular disease by causing hyperlipidemia and accelerating the metabolism of concomitant drugs used for their treatment. They can also facilitate the development of osteopenia and osteoporosis.
Conclusions and Relevance
Epilepsy affects approximately 65 million people worldwide and is associated with increased rates of bodily injuries and mortality when not optimally treated. For focal and generalized epilepsy, selection of ASDs should consider the seizure and epilepsy types and epilepsy syndrome, as well as the patient’s age and sex, comorbidities, and potential drug interactions.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Corresponding Author: Andres M. Kanner, MD, Comprehensive Epilepsy Center, Department of Neurology, University of Miami, Miller School of Medicine, 1120 NW 14th St, Room 1324, Miami, FL 33136 (firstname.lastname@example.org).
Accepted for Publication: February 28, 2022.
Author Contributions: Drs Kanner and Bicchi had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Both Drs Kanner and Bicchi contributed equally to the content of this manuscript.
Concept and design: Kanner.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Kanner.
Critical revision of the manuscript for important intellectual content: All authors.
Administrative, technical, or material support: Melo Bicchi.
Conflict of Interest Disclosures: Dr Kanner reported receiving personal fees from Epilepsy Foundation as compensation for his role as co-editor of Epilepsy.com and from Eisai Ltd as honoraria for lectures given at international meetings on psychiatric aspects of epilepsy and for participation in a scientific advisory board and receiving honoraria from Xenon Inc for participation in a scientific advisory board outside the submitted work. No other disclosures were reported.
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