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Topiramate and its Use in the Therapy of Epilepsy in the Elderly
European Neurological Review, 2006;(2):33-34
Epilepsy in the elderly is defined as first onset of epileptic seizures in patients from the age of 601,2 or, according to other authors, from the age of 65,3,4 respectively. It has been established that approximately one-third of patients with newly diagnosed epilepsy are older than 60 years and also half of all adult patients with known epilepsy are beyond an age of 60.5 The symptomatic focal epilepsy is the most frequently diagnosed type. Main causes are strokes6,7 followed by brain tumours4 and degenerative diseases of the brain.2 Regarding anticonvulsant therapy, physicians have to be aware of differences in the therapy of older patients. The brain of the elderly patient has a high sensitivity to centrally acting medication which may lead to fatigue and somnolence as well as cognitive side effects even at a low dose. Furthermore, physicians should be aware of a reduction in renal clearance and impaired hepatic metabolism of anti-epileptic drugs in the elderly. In addition, many patients of advanced age are suffering from chronic diseases requiring extensive non-anticonvulsant co-medication that can cause significant drug interactions. Therefore, an anti-epileptic drug used in the elderly patient ideally should have a low potential for cognitive impairment, an adequate clearance despite reduced metabolism and a low possibility for drug–drug interaction. Furthermore, the anticonvulsant used should be effective as monotherapy.
Taking these considerations into account, it is surprising that carbamazepine is still the most widely prescribed anti-epileptic drug in the German-speaking area, despite the advantages of recently approved anticonvulsant drugs. There are several studies investigating the efficacy or efficacy respectively of new anticonvulsants such as gabapentin, lamotrigine, levetiracetam, oxcarbazepine, tiagabine, topiramate and zonisamide in the epilepsy of the elderly.8–18 Unfortunately only two of these are randomized, controlled, double-blind studies.8,9 The aim of this report is to discuss the significance of topiramate in the therapy of epilepsy in the elderly.
In general, topiramate has advantages over previously established anticonvulsant drugs. A prospective, randomised double-blind study conducted by Privitera et al. 19 investigated the efficacy of topiramate 100mg or 200mg/per day compared with carbamazepine 600mg/day and valproic acid 1250mg/day in patients aged six and above.
- Bergey GK, “Initial Treatment of epilepsy (special issues in treating the elderly)”, Neurology (2004);63: pp. 40–48
- Read CL, Stephen LJ, Stolarek IH, et al., “Cognitive effects of anticonvulsant monotherapy in elderly patients: a placebo controlled study”, Seizure (1998);7: pp. 159–162
- Conway JM, Cloyd JC, “Antiepileptic drugs – combination therapy and interactions”, Maikowski J, Bourgeois B, Patsalos P and Mattson R (eds), Antiepileptic drug interaction in the elderly, Cambridge Univ Press (2005): pp. 273–293.
- Stefan H, “Epilepsien im höheren Lebensalter”, Neuro Ger (2005);2: pp. 17–20.
- Wrede R von, Elger CE, Neurogeriatrie, Deutschl G, Reichmann H (eds.), Anfallsleiden im Senium, Stuttgart, New York: Thieme, (2006): pp. 47–65.
- Bülau P, “Epilepsie nach Schlaganfall”, Neuro Ger (2005);2: pp. 57–66.
- Krämer G, Epilepsien im höheren Lebensalter, (1998) Stuttgart: Thieme.
- Rowan AJ, Ramsay RE, Collins JF, et al. and the VA Cooperative Study 428 Group, “New onset geriatric epilepsy: A randomized study of gabapentin, lamotrigine and carbamacepine”, Neurology (2005);64: pp. 1868–1873.
- Brodie MJ, Overstall PW, “Multicentre, double-blind, randomized comparison in elderly patients with newly diagnosed epilepsy”, Epilepsy Res (1999);37: pp. 81–87.
- Ferendelli JA, Frenck, J, Leppik I et al., “Use of levetiracetam in a population of patients aged 65 years and older, a subset analysis of the KEEPER trial”, Epilepsy Behav (2003);4: pp. 702–709.
- Kutluay E, McCaguek, D’Souza J, Beydoun A, “Safety and tolerability of oxcarbazepine in elderly patients with epilepsy”, Epilepsy Behav (2003);4: pp. 175–180.
- Pedersen B, “Epilepsy in the elderly: The use of tiagabine”, Epilepsia (2001);42: pp. 52–54.
- Mehta S, Pryor FM, Kraut L, et al., “Efficacy and tolerability of topiramate in the elderly population”, Epilepsia (2002);43: p. 165.
- Mauri JA, Tejero C, Garecen M, et al., “Topiramate monotherapy in elderly patients with epilepsy”, Epilepsia (2003);44: p. 198.
- Groseli J, Guerrini R, Van Oene J, et al., “Experience with topiramate monotherapy in elderly patients with recent-onset epilepsy”, Acta Neurol Scand (2005);112: pp. 144–150.
- Stefan H, Schäuble B, Schreiner A, “Efficacy and tolerability of topiramate in the treatment of epilepsy in elderly patients: Results of a Phase IV clinical trial”, Epilepsia (2006);47 (Suppl 3): p. 137.
- Runge U, Schreiner A, “Safety and tolerability of topiramate in elderly patients with epilepsy: Results from a prospective observational study”, Epilepsia (2006);47 (Suppl 3): p. 140.
- Tosche WA, Tisdell J, “Long-term zonisamide therapy in geriatric patients: efficacy and safety”, Epilepsia (2005); 46: p. 190.
- Privitera MD, Brodie MJ, Mattson RH, et al., “Topiramate, carbamazepine and valproate monotherapie: double-blind comparison in newly diagnosed epilepsy”, Acta Neurol Scand (2003);107: pp. 165–175.
Keywords: topiramate, epilepsy in the elderly, therapy, onset epileptic seizures