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May 2013

Older vs Newer Antiepileptic Drugs: Is Old Still Gold?

Author Affiliations

Author Affiliation: Comprehensive Epilepsy Center, New York–Presbyterian Hospital, Weill Cornell Medical Center, New York, New York.

JAMA Neurol. 2013;70(5):656-657. doi:10.1001/jamaneurol.2013.27

I read with interest the results from the KONQUEST (Keppra vs Older AEDs evaluating Neuropsychiatric, Neurocognitive and QUality of life outcomes in treatment of Epilepsy as Substitution monoTherapy) trial.1 The trial showed no difference in quality of life, neuropsychiatric, neurocognitive, seizure control, and adverse event outcome measures when patients with partial epilepsy who had failed monotherapy with an older antiepileptic drug (AED) were switched to monotherapy with another older AED vs those switched to brand name levetiracetam (marketed in the United States as Keppra; UCB Pharma). The efficacy and adverse effect profile of an AED may vary between the brand name medication and its generic equivalents available on the market. Were the patients who were taking older AEDs switched to brand name older AEDs or their generic equivalents? This may have skewed the results reported. Patients who are well controlled with older AEDs are at times switched to newer generation AEDs on the grounds that they have a more favorable adverse effect profile in the long run, namely, lesser incidence of neurocognitive and neuropsychiatric adverse effects, bone loss, and safety during pregnancy. Results from the KONQUEST trial make us pause and ponder this rationale as newer AEDs, especially those that lack a generic equivalent, are far more expensive and place a significant financial burden both on the patient and society at large.

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