The informed scientist

My task is to convince you that recently approved AEDs should be used early in the treatment of epilepsy if it likely to be beneficial for the individual patient. Recently approved AEDs are arbitrarily defined here as add-on AEDs such as eslicarbazepine-acetate, lacosamide and rufinamide that have been approved following the introduction of levetiracetam as add-on drug. For new onset focal epilepsy levetiracetam is considered to be a recently approved agent.
Add-on treatment of drug-resistant epilepsy: Early use is defined as the first add-on following the diagnosis of drug-resistant epilepsy as proposed by the ILAE (2010). Why should we use eslicarbazepine-acetate, lacosamide and rufinamide early as add-on drugs? There are at least three reasons to do so. 1. These AEDs are effective and safe if used prudently and only as approved. 2. Eslicarbazepine-acetate is an elegant prodrug for the well-known active metabolite of oxcarbazepine. All benefits and restrictions of OXC apply to eslicarbazepine- acetate. In that sense, eslicarbazepine-acetate is a well-known AED that can be used early for drug-resistant focal epilepsy. 3. Lacosamide is a well-known sodium blocker and as such its mechanism and had advantages (no drug interaction, no rash) over older sodium blocker such as carbamazepine and phenytoin. One would not expect unwelcome surprises here. 3. Rufinamide is one of few AEDs that has shown efficacy in Lennox-Gastaut-Syndrome and had safety/tolerability advantages of older AEDs such as valproate or felbamate. Monotherapy for recent-onset epilepsy: The early use of recently approved AEDs for new- onset cases such as levetiracetam for focal epilepsy is driven by the advantages of levetiracetam. These are similar efficacy vs. older AEDs and absence of rash and drug interactions. The propensity of levetiracetam to be involved in psychiatric side effects needs to be considered. Although this opinion supports the early use of approved new AEDs, caution is needed. Early use requires extra vigilance to detect previously unrecognised adverse events and, as in any case, treatment beyond the approved use is strongly discouraged.