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A summary of NICE guidance relating to the use of newer drugs for epilepsy in adults is presented below:
1.1 The newer antiepileptic drugs gabapentin, lamotrigine, levetiracetam, oxcarbazepine, tiagabine, topiramate and vigabatrin, within their licensed indications, are recommended for the management of epilepsy in people who have not benefited from treatment with the older antiepileptic drugs such as carbamazepine or sodium valproate, or for whom the older antiepileptic drugs are unsuitable because:
there are contraindications to the drugs
they could interact with other drugs the person is taking (notably oral contraceptives)
they are already known to be poorly tolerated by the individual
the person is a woman of childbearing potential (see Section 1.4 below).
1.2 It is recommended that people should be treated with a single antiepileptic drug (monotherapy) wherever possible. If the initial treatment is unsuccessful, then monotherapy using another drug can be tried. Caution is needed during the changeover period.
1.3 It is recommended that combination therapy (adjunctive or add-on therapy) should only be considered when attempts at monotherapy with antiepileptic drugs (as in Section 1.2) have not resulted in seizure freedom. If trials of combination therapy do not bring about worthwhile benefits, treatment should revert to the regimen (monotherapy or combination therapy) that has proved most acceptable to the patient, in terms of providing the best balance between effectiveness in reducing seizure frequency and tolerability of side effects.
1.4 In women of childbearing potential, the possibility of interaction with oral contraceptives and the risk of the drugs causing harm to an unborn child should be discussed and an assessment made as to the risks and benefits of treatment with individual drugs. There are currently few data upon which to base a definitive assessment of the risks to the unborn child associated with the newer drugs. Specific caution is advised in the use of sodium valproate because of the risk of harm to the unborn child.
1.5 It is recommended that all people having a first seizure should be seen as soon as possible by a specialist in the management of the epilepsies to ensure precise and early diagnosis and initiation of therapy as appropriate to their needs.
1.6 Treatment should be reviewed at regular intervals to ensure that people with epilepsy are not maintained for long periods on treatment that is ineffective or poorly tolerated and that concordance with prescribed medication is maintained.
1.7 The recommendations on choice of treatment and the importance of regular monitoring of effectiveness and tolerability are the same for specific groups such as older people and those with learning disabilities as for the general population.
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