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Neurology. 2018 Jul 10;91(2):74-81. doi: 10.1212/WNL.0000000000005755. Epub 2018 Jun 13.

Practice guideline update summary: Efficacy and tolerability of the new antiepileptic drugs I: Treatment of new-onset epilepsy: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Epilepsy Society.

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From the Miller School of Medicine (A.M.K.), University of Miami, FL; Bronson Neuroscience Center (E.A.), Bronson Methodist Hospital, Kalamazoo, MI; Department of Neurology (D.G.), Charleston Area Medical Center, Charleston, WV; Department of Neurology (C.H.), Mount Sinai Beth Israel, New York, NY; Children's Hospital (B.B.), Harvard Medical School, Boston, MA; Epilepsy Center (J.F.B.), Cleveland Clinic Foundation, OH; Department of Neurology (B.A.-K.), Vanderbilt University, Nashville, TN; Department of Neurology (E.B.-D.), Cooper Medical School, Rowan University, Cherry Hill, NJ; AMITA Health Medical Group (E.L.P.), Hoffman Estates, IL; School of Medicine (J.S.), University of California, Los Angeles; School of Medicine (D.H.), University of Vermont, Burlington; Children's Hospital (M.N.), University of California San Diego School of Medicine; School of Pharmacy (B.G.), University of Wisconsin, Madison; School of Medicine (E.F.), Emory University, Atlanta, GA; and Department of Neurology (J.F.), New York University Langone Comprehensive Epilepsy Center, New York.



To update the 2004 American Academy of Neurology (AAN) guideline for treating new-onset focal or generalized epilepsy with second- and third-generation antiepileptic drugs (AEDs).


The 2004 AAN criteria were used to systematically review literature (January 2003-November 2015), classify pertinent studies according to the therapeutic rating scheme, and link recommendations to evidence strength.


Several second-generation AEDs are effective for new-onset focal epilepsy. Data are lacking on efficacy in new-onset generalized tonic-clonic seizures, juvenile myoclonic epilepsy, or juvenile absence epilepsy, and on efficacy of third-generation AEDs in new-onset epilepsy.


Lamotrigine (LTG) should (Level B) and levetiracetam (LEV) and zonisamide (ZNS) may (Level C) be considered in decreasing seizure frequency in adults with new-onset focal epilepsy. LTG should (Level B) and gabapentin (GBP) may (Level C) be considered in decreasing seizure frequency in patients ≥60 years of age with new-onset focal epilepsy. Unless there are compelling adverse effect-related concerns, ethosuximide or valproic acid should be considered before LTG to decrease seizure frequency in treating absence seizures in childhood absence epilepsy (level B). No high-quality studies suggest clobazam, eslicarbazepine, ezogabine, felbamate, GBP, lacosamide, LEV, LTG, oxcarbazepine, perampanel, pregabalin, rufinamide, tiagabine, topiramate, vigabatrin, or ZNS is effective in treating new-onset epilepsy because no high-quality studies exist in adults of various ages. A recent Food and Drug Administration (FDA) strategy allows extrapolation of efficacy across populations; therefore, for focal epilepsy, eslicarbazepine and lacosamide (oral only for pediatric use) as add-on or monotherapy in persons ≥4 years old and perampanel as monotherapy received FDA approval.

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