The 1980s had been a time of crisis for epilepsy care. No new major antiepileptic drugs were released since 1978 and none were in the pipeline. Although there were many older seizure medications available, most were not well tolerated. Drug therapy was limited primarily to phenytoin (Dilantin), carbamazepine (Tegretol), barbiturates (phenobarbital and primidone) and valproic acid (Depakote). This left only a limited number of options for therapy.

Fortunately, this large gap in epilepsy therapy was recognized, and after a 15 year drought in the U.S., a steady stream of new antiepileptic drugs has appeared. Beginning in 1993, the FDA approved four new drugs and two new formulations. The new drugs include felbamate (Felbatol), gabapentin (Neurontin), lamotrigine (Lamictal) and topiramate (Topamax). The new formulations include sustained release carbamazepine (Tegretol XR) and intravenous valproate (Depacon). In addition, it is anticipated that there will be two new drugs released in 1997 -- tiagabine (Gabatril) and vigabatrin (Sabril).

The availability of these new medications has left clinicians with the dilemma of when and how to use them. The long status quo has actually made some physicians resistant to change. Financial pressures to minimize health care costs have have also limited some physicians from using the new seizure medications. Does this mean this new boom is a bust?

Not by any means.

To understand how the role of new medications, it is only necessary to look at the shortcomings of epilepsy therapy.

1. We need new drugs to improve seizure control.

It is estimated that about 20% of persons with epilepsy remain uncontrolled on seizure medications. Thus, the most obvious reason for new medications is to improve seizure control in these persons. In the clinical trial that led to FDA approval, each of the new medications were given to persons that were medically resistant to previous seizure medications. The good news is that about 20-30% of these persons with drug-resistant epilepsy had a good improvement (at least 50% reduction of seizures). As more medications become available, the odds that an individual will find a medication that is effective will increase greatly.

2. We need new drugs to reduce side effects.

Side effects have almost been a fact of life for persons with epilepsy. All seizure medications can potentially cause problems with drowsiness, impaired thinking, unsteadiness of walking, slurred speech and many other problems. Interestingly, while a particular individual may have a difficult time with one medication, another may cause no difficulties. Thus, the adage "one man's meat is another man's poison" is no truer than in the case of seizure therapy. However, in the past, drug therapy was limited to only a few seizure medications, and many persons had to simply "put up" with side effects. The availability of new medications makes it much more likely that a medication can be used with little or no side effects. Furthermore, many of the new medications seem to have less side effects overall. Reducing side effects will be an important part of improving the quality of life for persons with epilepsy.

3. We need new drugs that interact less with other medications.

Almost all of the older medications have strong interactions with other medications that raise and lower blood levels. Several of the new medications have small or no drug interactions. As the population becomes older, multiple drug therapy, for ailments such as high blood pressure and heart problems, will be more common. It will be especially important to have medications with low drug interactions.

Who should try the new seizure medications?

The new medications hold great promise to improve the quality of life for persons with epilepsy. However, if your epilepsy is well controlled and you have no problem with side effects, there is no reason to make any changes in your medication. On the other hand, if you have problems with uncontrolled epilepsy and/or problem with side effects, consider reviewing with your doctor the possibility of trying the new seizure medications.