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Study questions NICE advice on epilepsy drugs

By Cato Pedder

Controversial epilepsy drug sodium valproate is much more effective than lamotrigine and topiramate in treating idiopathic generalised epilepsy (IGE), a new study reveals.

The Committee on Safety of Medicines last year banned GPs from giving valproate to women of childbearing age without specialist advice after research found treatment with the drug doubled the risk of birth defects compared with other anti-epileptic drugs.

But the new study, published in this month's Journal of Neurology, Neurosurgery and Psychiatry, found valproate was so effective that combination therapy using the drug should be initiated even if valproate monotherapy was not successful, rather than switching to an alternative monotherapy.

This finding is contrary to draft National Institute for Clinical Excellence guidance on the treatment and management of epilepsy. This recommends that combination therapy should only be considered when all monotherapy options have been exhausted.

The study of 962 IGE patient records found that 52.1 per cent of patients on valproate alone achieved a year of remission.

Topiramate and lamotrigine performed significantly less well with remission rates of 34.6 per cent and 16.7 per cent respectively in patients with IGEs.

In patients who stopped taking valproate because it did not control seizures, none achieved remission when given the alternative lamotrigine monotherapy.

But 10 out of 83 patients who received lamotrigine alongside valproate achieved remission.

Up to 30 per cent of people with epilepsy have IGE and study leader Dr Andrew Nicolson said although the NICE approach was appropriate for most types of epilepsy, patients with IGE had different treatment needs.

He said: 'There are fewer drugs available on the market that work in this condition and the guidelines should differentiate between the different forms of epilepsy.'

Dr Nicolson, a specialist registrar in neurology at Hope Hospital in Salford, said: 'Valproate may be the most effective anti-epileptic drug in the treatment of IGEs.'

He added that he would not choose valproate as the first-line treatment in young women with IGE but, he said, 'they should be aware that any other treatment might not be as effective'.

Dr Jim Morrow, consultant neurologist at the Royal Victoria Hospital in Belfast and lead researcher on the UK Epilepsy and Pregnancy Register, said: 'In my opinion sodium valproate remains an appropriate drug for some women of childbearing age, provided an informed choice has been made.'

The study also found the relapse rate was high (79.9 per cent) after anti-epileptic drug withdrawal in remission, suggesting that treatment needs to be lifelong in many adult patients with IGE.

A NICE spokesman said the study had come too late for its findings to influence the draft guidance.

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