INCREASINGLY we are forced to choose between the ideal and the affordable. Both Pierre-Louis and Bergen agree that a physician should begin with first-generation drugs in the treatment of epilepsy, but they differ in what should be available among the second-generation drugs. Pierre-Louis wants all drugs to be available, while Bergen wants them selected on the basis of cost-effectiveness studies.
While as a group, second-generation antiepileptics tend to have more specific sites of action and fewer adverse effects, it is not certain that they are more effective. The only certainty is that they are more costly. But they cannot be judged by cost alone. As Bergen points out, although the recently approved fosphenytoin is 100 times more expensive than generic phenytoin, studies suggest that it is worth the price in terms of treatment of complications.
Hachinski V. New Antiepileptic Drugs: Should All Be Made Available? Arch Neurol. 2000;57(2):275. doi:10.1001/archneur.57.2.275
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