NICE guidance - use of newer drugs for epilepsy in children

Summary points from the NICE Guidance are presented below (1):

1.1 The newer antiepileptic drugs gabapentin, lamotrigine, oxcarbazepine, tiagabine, topiramate, and vigabatrin (as an adjunctive therapy for partial seizures), within their licensed indications, are recommended for the management of epilepsy in children 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 child is taking (notably oral contraceptives)

they are already known to be poorly tolerated by the child

the child is currently of childbearing potential or is likely to need treatment into her childbearing years (see Section 1.5 below).

1.2 Vigabatrin is recommended as a first-line therapy for the management of infantile spasms (West's syndrome).

1.3 It is recommended that children 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.

1.4 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 1.3) 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 child, in terms of the balance between effectiveness in reducing seizure frequency and tolerability of side effects.

1.5 In girls of childbearing potential, including young girls who are likely to need treatment into their childbearing years, the risk of the drugs causing harm to an unborn child, and the possibility of interaction with oral contraceptives, should be discussed with the child and/or their carer, and an assessment made as to the risks and benefits of treatment with individual drugs. There are currently few data on which to base a definitive assessment of the risks to the unborn child associated with newer drugs. Specific caution is advised in the use of sodium valproate because of the risk of harm to the unborn child.

1.6 It is recommended that all children who have had a first non-febrile 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.

1.7 Treatment should be reviewed at regular intervals to ensure that children with epilepsy are not maintained for long periods on treatment that is ineffective or poorly tolerated and that concordance with prescribed medication is maintained.

1.8 The recommendations on choice of treatment and the importance of regular monitoring of effectiveness and tolerability are the same for specific groups, such as children with learning disabilities, as for the general population of children with epilepsy.

For more details then consult full guidance (1).

Reference:

1. NICE (April 2004). Newer drugs for epilepsy in children.