A pragmatic algorithm to select appropriate antiseizure medications in patients with epilepsy

Abstract

Objective: Antiseizure medications (ASMs) are the first-line treatment for epilepsy. Many ASMs are available; this offers the opportunity to improve therapy by tailoring it to individual characteristics, but also increases the possibility of healthcare professionals making inappropriate treatment choices. To assist healthcare professionals, we developed a pragmatic algorithm aimed at facilitating medication selection for individuals whose epilepsy begins at age 10 years and older. Methods: Utilizing available evidence and a Delphi panel−based consensus process, a group of epilepsy experts developed an algorithm for selection of ASMs, depending on the seizure type(s) and the presence of relevant clinical variables (age, gender, comorbidities, and comedications). The algorithm was implemented into a web-based application that was tested and improved in an iterative process. Results: The algorithm categorizes ASMs deemed to be appropriate for each seizure type or combination of seizure types into three groups, with group 1 ASMs considered preferred, group 2 considered second line, and group 3 considered third line. Depending on the presence of relevant clinical variables, the ranking of individual ASMs is adjusted in the prioritization scheme to tailor recommendations to the characteristics of the individual. The algorithm is available on a web-based application

Optimal choice of antiseizure medication: Agreement among experts and validation of a web‐based decision support application

“…Lack of availability/affordability is a particularly important consideration in low‐income settings. Keeping this in mind, ASMs that were present in the primary step of the nesting process (based on the seizure type) and were downgraded below Group 3 after adjustment for modifiers were not removed, but were displayed as “Least desirable options if the above drugs are not available” in order to broaden selection options to facilitate selection in settings where few medications are available or affordable 12 . The app was designed to offer a range of choices, recognizing that there is often more than one optimal ASM and that local drug availability and prescribed preferences must be considered.…”

“…The algorithm takes into account the teratogenicity of valproate. In premenopausal females, valproate is completely removed from the list of recommended ASM 12 . However, in certain cases of idiopathic/genetic epilepsies, valproate can be a valid choice 28‐30 .…”

“…After obtaining the experts' responses, clinical details of each case were entered into the app, and the preferred ASM ranking generated by the app's software for each case were recorded. The algorithm used by the software is described elsewhere 12 . The ASMs ranked highest (Group 1) by the app for each case were then compared with the ASMs selected most commonly by the experts for that case (expert selections).…”

“…To assist healthcare professionals who manage people with epilepsy, we developed a web‐based decision support application (EpiPick), aimed at facilitating appropriate selection of ASMs in monotherapy for people with seizure onset at age 10 years and older 12 . The application is freely available at: https://epipick.org.…”

“…The application is freely available at: https://epipick.org. Based on patient‐specific characteristics, entered by the user, the algorithm provides a suggested ranking of ASMs in order of likely appropriateness for that individual, as well as textual prescribing information on each of the ranked ASMs 12 …”