Pharmacotherapy: Agents, efficacy, clinical trials, and which drug to choose

Research output: Contribution to journalShort surveypeer-review

Abstract

Epilepsy in the elderly is more prevalent than commonly believed.With a few exceptions, selection of AED therapy for older patients has been extrapolated from the results of trials in young adults. Although open-label, uncontrolled trials do not prove efficacy, they help the clinician learn about the tolerability of AEDs and practical suggestions for their use. Double-blind, prospective comparative AED trials in the elderly patient with epilepsy have demonstrated that the newer AEDs gabapentin or lamotrigine are better tolerated than the standard AED carbamazepine, and there is less likelihood of an older patient to stop taking gabapentin or lamotrigine due to intolerable adverse effects or lack of efficacy. A study comparing the effectiveness of levetiracetam to carbamazepine in older patients with epilepsy is currently underway. A prospective study comparing the effectiveness of all available AEDs in older patients (or any age group for that matter) is time and labor-intensive, as well as statistically prohibitive. Each patient should be treated individually. Affordability of an AED is a must since there is no sense in prescribing an AED that the patient does not have access to. The first given responsibility of health providers is to do no harm. In patients with liver disease, AEDs that are metabolized in the liver may be avoided or their doses adjusted at the least. Patients with renal disease may need significantly smaller doses to maintain therapeutic effect. AEDs associated with renal stones may not be choice drugs for patients with personal or family history of renal stones. AEDs that may accelerate osteoporosis should especially be avoided in frail older patients. Patients taking sodium-losing drugs may have clinically significant hyponatremia should AEDs associated with hyponatremia be added. AEDs associated with tremor may significantly impair the quality of life of patients with preexisting tremor. Patients with known allergies to certain drugs should not be exposed to AEDs known to have cross-reactivity with those drugs. AEDs associated with agitation and irritability should be used carefully in patients with prior history of hostility or impulse dyscontrol. To minimize pharmacokinetic drug interactions, patients may benefit better from AEDs that are not metabolized in the liver or highly protein-bound. AEDs associated with weight gain or weight loss should be regarded with caution in obese and slim patients, respectively. On the other hand, patients with epilepsy and problems related to headache, insomnia, mania, depression, overweight, underweight, or neuropathic pain may welcome an AED with antimigraine, hypnotic, antimanic, antidepressant, weight loss, weight gain, or analgesic properties, respectively. Finally, as older patients may be more sensitive to AEDs where intolerable adverse effects may occur at lower doses and efficacy at lower serum levels compared to younger adults, it behooves health providers to start AED doses low and titrate slow.

Original languageEnglish (US)
Pages (from-to)3-5
Number of pages3
JournalClinical Geriatrics
Volume15
Issue number6 SUPPL. 1
StatePublished - Jun 2007
Externally publishedYes

ASJC Scopus subject areas

  • Geriatrics and Gerontology

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