Pharmacological treatment of focal epilepsy in adults: an evidence based approach

ABSTRACT

Introduction

Focal seizures represent the most common seizure type and focal epilepsies the most common epilepsy type. Anti-seizure medications (ASMs) still represent the main form of treatment for epilepsy.

Areas covered

The aim of this review article is to provide an overview of available evidence about current and upcoming pharmacological options and strategies for adults with focal epilepsy focusing on the last 5 years.

Expert opinion

Seventeen drugs are currently approved for the treatment of focal seizures including cenobamate as the very latest option. Ten of these drugs are also licensed for monotherapy. Level A evidence for initial monotherapy is available for seven drugs with no robust data supporting that one drug is superior to the other. Safety, tolerability as well as pharmacoeconomic reasons would then drive treatment decisions. Data on adjunctive treatment are available for 13 ASMs showing again no obvious difference in terms of efficacy. Evidence on specific drug combinations is almost non-existent and the final decision of combining specific drugs is based on the experience of the individual clinician rather than on robust evidence. Current outcome measures do not consider number of previously failed drugs and the observation period is often too short.

KEYWORDS:

• Epilepsy
• focal
• treatment
• outcome
• antiepileptic drugs
• antiseizure medications
• cenobamate

Article highlights

• Seventeen drugs are currently licensed for the treatment of focal seizures

• Level A of evidence for the initial monotherapy of focal seizures is available for seven drugs with no difference in terms of efficacy

• Data on adjunctive treatment are available for 13 drugs with no difference in terms of efficacy

• Lamotrigine and levetiracetam represent the best options when efficacy safety and tolerability are considered

• Evidence of specific drug combinations is non-existent and clinical practice is based on the experience of the individual clinician

• Head-to-head comparison studies using appropriate outcome measures are needed

This box summarizes key points contained in the article.

Declaration of interest

M Mula has received personal fees from UCB, Eisai, Bial, and Elsevier all outside the submitted work. Furthermore, M Mula has intellectual property rights with Springer and Elsevier. He has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript has not been funded.