Epilepsy and the Evolving Treatment Choices

Trevor Resnick, MD: That’s an interesting question because perampanel and many of the older medications, because of a change in the FDA regulations, are now approved for epilepsy. So this whole issue of indications for second-line treatment, first-line treatment, adjunctive treatment, [and] new-onset epilepsy is gone. So a lot of these medications are now being viewed as if a patient has epilepsy and they’re above 4 years of age, in general, because that’s the way the newer shift has occurred. Those patients are eligible to use the medication for the kind of epilepsy that medication is approved for. So a lot of medications, such as lacosamide, such as perampanel and some of the other medications, are now approved for monotherapy for epilepsy at 4 years and above. So now when pediatric [epileptologists] and [neurologists] see patients with new-onset epilepsy, we have a much larger armamentarium of medications to choose from because now most of them are approved for monotherapy treatment in epilepsy.

So you’d ask me the question about perampanel. And as far as perampanel is concerned, it is approved now down to 4 years of age for partial-onset seizures and for seizures that become secondary generalized. It does have very robust efficacy for patients who have either secondary generalized seizures or primary generalized seizures. So you have a large number of choices for partial-onset seizures. But specifically, as it relates to generalized epilepsy and the effectiveness of perampanel for generalized epilepsy, regardless of whether it’s primary or secondary generalized epilepsy, there are fewer drugs to choose from. And because perampanel has demonstrated effectiveness in that group of patients, it becomes a drug that we consider much, much earlier either as monotherapy or adjunctive therapy for generalized seizures.

I’ve been treating epilepsy for the last 35 years and have seen tremendous changes in the antiepileptic drug choices, the tolerability issues, the issues that relate to compliance, half-life, and newer drug development that allows once-a-day dosing. But as far as managing breakthroughs, I think counseling, first of all, is a major issue. [We need to speak] to families and [tell] them, “Look, I don’t want you to have tolerability issues. So rather than not taking your medication, let me know immediately so we can try [to] figure out a way around it.” And [talk] to them about the risk of breakthrough seizures with [nonadherence]. Also [talk] to them about SUDEP, which is sudden [unexpected] death in epileptic patients, because although it does create fear, it also creates a reality basis of why it’s so important to take your medication. So I think really good communication, looking at all the different options and providing an open forum for communication for the patients, I think makes it much more likely that you’ll get [adherence] and decrease the frequency of breakthrough seizures.

R. Edward Faught, MD: Well, we’ve had drugs for seizures for 150 years, but starting [in the] early 1990s, we began to get a number of new drugs that are not always more effective, but they have fewer [adverse] effects and [are] easier to use. So every time a new drug comes along, we find some people for whom it’s just the thing, it’s exactly what they need. And it’s hard to predict that in advance. So treating epilepsy [is] still a trial-and-error process to some extent. We try to pick out a drug that’s appropriate for the patient’s seizure type and be sure they can tolerate it, because these are drugs that they have taken for many, many years. So both these drugs have [proven] to be effective and useful.

Trevor Resnick, MD: The impact is significant for patients for epilepsy, 1 from a psychological standpoint. So a lot of patients whose seizures have been well controlled, and they don’t have to think about the fact of when [they are] going to have [their] next seizure, and then all of a sudden they have a breakthrough seizure. And it kind of resets the whole picture for them. If you talk to them, they will say after you’ve had a seizure and you’ve been to the emergency [department], you think about when you’re going to have your other one. And the further away you get from your last breakthrough seizure, you think about it less and less. And the impact that has on your daily life is significant. Also, there are morbidities relating to breakthrough seizures, injuries, visits to the emergency [department]. So it really is a major negative impact on daily life and then [on] the way those patients function in a period of time there afterward.

Now, if you had to think of it, depending on work you’re involved in—those people who are involved in manual labor or [are] truck drivers—the impact of having a seizure is significant, even if it’s not while you’re driving a truck. [You] driving a truck is significant, but if you’re not driving the truck—…[if] you can’t drive afterward—it affects your ability to earn money. Now, if you’re involved in a white-collar job, it still has an effect because it affects the people around you. It affects the way they view you. But at least you can go back to work, and you’re not going to do anybody any harm. But if you think of the labor force and the impact of having a seizure on the kind of work you do, it’s a major impact.