New epilepsy treatments cause fewer side effects in the elderly than carbamazepine.
The newer antiepileptic drugs (AEDs), gabapentin (Neurontin) and lamotrigine (Lamictal), were matched against the enzyme inducer, carbamazepine, in an 18-center randomized double-blind study of 593 patients that lasted 1 year, said A. James Rowan, M.D., a professor of neurology at Mount Sinai School of Medicine, New York.
Of the two newer drugs, lamotrigine was significantly superior to gabapentin from the standpoint of patient retention over the length of the study. Neither of the newer agents was significantly better than carbamazepine in preventing seizures, said Dr. Rowan, who was codirector of the VA study.
The trial also found that optimal doses of AEDs may be lower in the elderly patients, he reported at a meeting on epilepsy in the elderly sponsored by Boston University. The mean plasma levels of all three drugs were low "but that seems to be enough for this population," he said.
The patients were 60 years or older (mean age 72.8 years) with a history of one or more seizures and no previous AED therapy, or inadequate therapy. Aside from patients with medical conditions that suggested they would not survive for a year, "we took all comers, with multiple illnesses and multiple medications--the real world," Dr. Rowan said.
The patients were titrated to the target doses, 600 mg for carbamazepine, 1,500 mg for gabapentin, and 150 mg for lamo trigine. Clinicians had the flexibility to titrate further for tolerability, and after 12 months the mean doses were 582 mg for carbamazepine, 1,614 mg for gabapentin, and 152 mg for lamotrigine. "It was very much like office practice," he said.
At the end of 12 months, "carbamazepine had significantly more side effects than lamotrigine or gabapentin," which led to earlier termination of therapy, Dr. Rowan said. In the nursing home world, he added, adverse side effects and drug interactions, which are often promptly noted and reported in younger epilepsy patients, may be unnoticed or underreported among the elderly.
Of the 197 original carbamazepine patients, 72 finished the study (37%). That compared with 95 of 193 gabapentin patients (49%) and 114 of 197 patients in the lamotrigine arm (58%). Yet despite lamotrigine's reputation for having no side effects, Dr. Rowan said, "it does have side effects in the elderly."
Among the neurologic side effects, carbamazepine led to sedation for 51%, cognitive symptoms for 32%, dizziness for 32%, mood alteration for 4%, and gait disturbance for 29%. By contrast, in the gabapentin arm 46% of patients reported sedation; 29%, cognitive symptoms; 28%, dizziness; 26%, mood alterations; and 29%, gait disturbances. In the lamotrigine arm, 40% reported sedation, 23% cognitive symptoms, 27% dizziness, 30% mood alteration, and 28% gait disturbance.
RELATED ARTICLE: Resources Address Needs of Elderly
For help in meeting the needs of elderly patients, these resources are now available:
* Services for older adults. The Administration on Aging offers an eldercare locator to help put older adults into contact with assistance agencies and provide caregivers with training or a break from responsibilities. Call 800-677-1116 or visit www.eldercare.gov.
* Links for doctors. AARP's AgeLine includes a section with links to physician information about older adults. Topics include exercise, geriatric assessment, and Medicare coverage. Visit http://research.aarp.org/ageline/providertogo.html.
* Exercise for older adults. The National Institute on Aging offers a free guide for older Americans. "Exercise: A Guide From the National Institute on Aging" is available in English or Spanish. Call 800-222-2225 or visit www.niapublications.org/exercisebook/index.asp.
* Data on aging. The Centers for Disease Control and Prevention and the Merck Institute of Aging & Health have released the 2004 "State of Aging and Health in America Report." The report includes national and state-by -state report cards on healthy aging. Visit www.cdc.gov/aging/publications.htm.
BY MARK BLOOM
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|Publication:||Internal Medicine News|
|Date:||Jan 15, 2005|
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