Step Therapy Is Not Appropriate for Antiepileptic Drugs

We read with interest the article by Payakachat and colleagues, comparing the clinical practice guidelines for treatment of new-onset epilepsy in adults.1 While we appreciate their efforts to provide a careful review of available treatment guidelines and consideration of how these guidelines might be applied in managed care, we strongly disagree with their conclusion that older agents (i.e., phenobarbital, carbamazepine, phenytoin, and valproate) are the preferred first-line treatments for new-onset epilepsy. Their conclusions appear to be based upon a rather narrow consideration that only accounts for efficacy in controlling seizures. As the authors correctly note, broader data on the effectiveness, outcomes, tolerability, and quality of life are lacking in the published literature. However, the authors underemphasize important aspects of epilepsy as a disorder and characteristics of antiepileptic drugs that must be a part of therapeutic and formulary decision making. Indeed, the guidelines that are included in the article make specific statements about drug selection in epilepsy contrary to the conclusion of Payakachat et.al. The following are important factors, essential to therapeutic decisions in new-onset epilepsy, that had they been included would probably have led to a different conclusion.