Abstracts

RATIONALE: With the recent proliferation of antiseizure medications, devices for epilepsy, and new surgical techniques, the clinician is faced with an increasing number of treatment options. The available literature does not adequately address the optimum use of these therapies. We surveyed U.S. epileptologists for their opinion on the treatment of epilepsy.
METHODS: We developed a questionnaire that specified 808 treatment options across 23 clinical situations. Broad topics included partial and generalized epilepsy and the treatment of status epilepticus. Respondents rated each treatment option using a modified RAND 9-point scale of appropriateness (with 9 being the most appropriate). The treatment of choice was defined as the option that more than 50% of the respondents rated as [dsquote]9[dsquote]. The questionnaire went to 51 opinion leaders in the field of epilepsy. Data were interpreted based on the distribution of ratings, the 95% confidence interval and the mean rating.
RESULTS: 47 of 51 (92%) experts responded. The experts reached consensus on 89% of the options. As the initial treatment of idiopathic generalized epilepsy, regardless of the predominant seizure type, the panel chose valproate as the treatment of choice. As initial treatment of partial epilepsy, carbamazepine was the treatment of choice. For women in their reproductive years, the panel chose lamotrigine for idiopathic epilepsy, and carbamazepine for partial epilepsy. In pregnant and breast-feeding women, lamotrigine was preferred in both situations. In the elderly, lamotrigine was the preferred treatment of epilepsy. As initial treatment of all types of status epilepticus, lorazepam was the treatment of choice. If status continued, IV fosphenytoin was chosen as the second agent for partial status; IV valproate was selected as the second agent in absence status. If a decision was made to proceed to iatrogenic coma, IV pentobarbital was preferred for generalized and partial status; IV benzodiazepines were preferred in absence status epilepticus.
CONCLUSIONS: Using the Expert Consensus Method, the panel of opinion leaders reached consensus regarding the best treatment(s) for many of the clinical situations. In most situations, the experts were required to extrapolate beyond information that has been gathered in controlled clinical trials. They clearly recommended specific therapies, often preferring newer medications. Within the limits of expert opinion, and with the understanding that new research may take precedence, this method may provide sensible answers to common clinical questions. This type of information is most helpful when it is combined with evidence-based data.
Support: Abbott
Glaxo Smith Kline
Novartis
Disclosure: Honoraria - Abbott, Glaxo Smith Kline, Pfizer, Novartis, OrthoMcNeil, UCB Pharma, Elan Pharma