Childhood Absence Epilepsy
There is evidence to support the use of VPA, ethosuximide (ETX), and LTG as initial monotherapy for CAE . No evidence currently suggests that any of these has superior efficacy or effectiveness. There is, however, an ongoing multicentre trial, supported by the United States National Institutes of Health, to address this question.
Ideally, the goal in treating JME is to eliminate all seizure types. When this is not possible, targeting the most disabling seizure type, while avoiding obvious triggers (sleep deprivation and alcohol) is reasonable. While VPA has traditionally been used as the first-line AED in JME, there are no controlled trials to support this. In fact, no controlled trials have studied any AED as initial monotherapy for patients with JME. There is evidence from case series and open-label trials to support the use of VPA, LTG, LVT, TPM and zonisamide (ZNS) . However, LTG has also been reported to exacerbate myoclonic seizures in JME. Therefore, in a patient for whom the myoclonus is the primary concern, with infrequent convulsions, LTG may not be the AED of choice .
Additional consideration should be given to the fact that JME patients typically require lifelong AED therapy. For adolescent females, concerns regarding teratogenicity may argue against VPA as a first-line agent . Interactions with oral contraceptives should also be considered (see Table 5.4).
Primary Generalized Epilepsy with Tonic-Clonic Seizures Alone
There are few data to support evidence-based selection of AEDs for primary generalized tonic-clonic seizures alone. The available choices are the same as those discussed for JME: VPA, LTG, LVT, TPM and ZNS.
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