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Old drugs beat new for epilepsy

Standard epilepsy drugs are not only cheaper than newer alternatives but also better, a major UK trial reports.

The study, published in the latest issue of The Lancet, placed valproate as first-choice in general epilepsy and questioned NICE guidance for treatment of partial disease

An accompanying editorial insisted the results challenged the 'new is better than old' philosophy perpetuated by the pharmaceutical industry.The study aimed to overcome the methodological problems that have dogged previous comparisons of new and old epilepsy drugs, which have largely been company-funded.

It found that in 716 patients with general epilepsy, those on valproate went 1.5 times longer before treatment failure than with lamotrigine and 1.9 times longer than with topiramate – the newest of the three drugs.

In a second arm of the study, involving 1,721 patients with partial epilepsy, lamotrigine had a longer time to treatment failure or 12-month remission than carbamazepine – recommended by NICE as first choice for these patients.

Study leader Dr Anthony Marson, reader in neurology at the University of Liverpool, told Pulse he expected NICE to consider his data when it next reviewed its guidance on the management of epilepsy.

Dr Marson said: 'I expect our research will bring about a change, as the current recommendation is for carbamazepine. In light of this evidence, I think experts will change their practice.'

On the use of valproate – which is less expensive than many of the newer epilepsy drugs – as first-line for general epilepsy, Dr Marson said: 'It's likely in the long term it will save money for the NHS.'But he added the caveat that valproate should not be considered as a first-line drug for pregnant women because of the potential for birth defects.

Dr Greg Rogers, a GPSI in epilepsy in Cliftonville, Kent, said there was growing acceptance that valproate and lamotrigine should be the drugs of choice: 'It's very useful for us as we now have evidence to confirm our suspicions.'

Dr Jacqueline French, professor of neurology at the University of Pennsylvania in the US, wrote in her editorial: 'The answer is satisfying for physicians in general practice, who are overwhelmed by the number of anti-epileptics, and will welcome a clear-cut strategy for therapy.'

How the study worked

Arm A

• Recruited 1,721 UK patients with partial onset seizures for whom carbamazepine was the standard treatment

• Compared lamotrigine with carbamazepine, gabapentin, topiramate and oxcarbazepine

• Lamotrigine was significantly better than carbamazepine, the standard drug treatment for time to treatment failure outcomes

Arm B• Recruited 716 UK patients with generalised epilepsy for whom valproate was the standard treatment• Compared valproate with lamotrigine and topiramate• Valproate was better tolerated than topiramate and more efficacious than lamotrigine

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