National Institute for Health and Clinical Excellence (NICE)
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New advice on anti-epileptic drugs
New recommendations on the use of anti-epileptic drugs (AEDs) for the treatment of adults and children with epilepsy have been set out, in updated NICE guidelines.
Epilepsy affects up to an estimated 415,000 people in England, and two-thirds of people with active epilepsy have their condition satisfactorily controlled by AEDs.
NICE first published guidance on epilepsy in 2004 that included recommendations on the use of AEDs, as well as advice on the diagnosis, treatment and further management of the condition.
As recent years have seen a rise in the number of AEDs being prescribed, NICE has now updated this clinical guideline to provide information on newer AEDs.
The update describes how and when newer AEDs should be considered alongside older medicines, and can help GPs ensure they are prescribing treatments that are effective both clinically and cost effective.
NICE recommends that when possible, clinicians should choose which AED to offer on the basis of the presenting epilepsy syndrome. If the epilepsy syndrome is not clear at presentation, base the decision on the presenting seizure type(s).
When prescribing sodium valproate to women and girls of present and future childbearing potential, GPs should discuss the possible risk of malformation and neuro-developmental impairments in an unborn child. This is particularly the case with high doses of the AED or when using it as part of polytherapy.
Buccal midazolam or rectal diazepam should only be used in the community for children, young people and adults who have had a previous episode of prolonged or serial convulsive seizures, says NICE.
In addition, buccal midalozam should be administered as first-line treatment in children, young people and adults with prolonged or repeated seizures in the community.
GPs should prescribe rectal diazepam, if this is preferred, or if buccal midazolam is not available.
If intravenous access is already established, and resuscitation facilities are available, intravenous lorazepam should be administered.
Dr Greg Rogers, a GPwSI in epilepsy who was involved in the development of the updated guidelines said: “Epilepsy is the most common serious neurological disorder that we encounter in the UK.
“Whilst the majority of people with active epilepsy can satisfactorily control recurrent seizures, many still suffer from ongoing seizures and helping them to become seizure-free can help improve their health outcomes.
“This updated guideline is welcome as it incorporates the newer AEDs which have emerged in the UK since the original guidance was published in 2004.
“With the current uncertainty over whether these newer medicines bring any additional clinical benefits for their price, this guideline update helps inform GPs of their therapeutic choices.
“The use of levetiracetam is of particular interest as the last decade has seen its use increase. It is an effective and well tolerated drug but also expensive. Therefore, guidance on the use of this AED is welcome and on where it should be placed in the treatment of people with epilepsy.”
Elsewhere, the updated guideline contains a new recommendation on use of the ketogenic diet - a diet that is high in fat but low in carbohydrates and protein.
NICE says that if a child or young person with epilepsy has seizures that have not responded to appropriate AEDs, GPs should refer them to a tertiary paediatric epilepsy specialist to be considered for the ketogenic diet.
NICE has produced a range of tools to help support the implementation of this guideline, including a baseline assessment tool, clinical audit tools and a range of pharmacological treatment tables.
The guideline is also available to view as a NICE Pathway - our new online tool that provides quick and easy access to guidance recommendations.