Payakachat Nalin, Summers Kent H, Barbuto John P
Department of Pharmacy Practice, Purdue University, West Lafayette, IN 47907, USA.
J Manag Care Pharm. 2006 Jan-Feb;12(1):55-60. doi: 10.18553/jmcp.2006.12.1.55.
Clinical practice guidelines (CPGs) are intended not only to provide supportive information for health care providers but also to act as a guide for health care policy decisions. However, extant CPGs do not always reach the same conclusions. The objective of this study was to compare recommendations for initial pharmacological treatment of new-onset epilepsy in adults as stated within published CPGs.
We performed a systematic review of CPGs, which were published by prominent national organizations between January 2000 and June 2005, regarding the initial pharmacological treatment of epilepsy in adults.
Five CPGs and 1 evidence report were identified that focus on pharmaceutical management in epilepsy. The 3 guidelines most relevant to the question of new-onset epilepsy treatment in adults were developed by the American Academy of Neurology (AAN), Scottish Intercollegiate Guidelines Network (SIGN), and National Institute for Health and Clinical Excellence (NICE). AAN recommends the use of both recently introduced antiepileptic drugs (AEDs: gabapentin, lamotrigine, topiramate, and oxcarbazepine) and standard agents (carbamazepine, phenytoin, valproic acid/divalproex, and phenobarbital) in newly diagnosed epilepsy, i.e., a nontiered approach. Alternatively, NICE recommends using newer AEDs (lamotrigine, topiramate, and oxcarbazepine) only in patients who derive no benefit from older agents--a tiered approach. SIGN notes that all AEDs licensed for monotherapy have similar efficacy in newly diagnosed epilepsy--a recommendation for a nontiered approach. The newer AEDs (lamotrigine and oxcarbazepine) are recommended as first-line initial treatment as are standard agents (carbamazepine and valproic acid/divalproex). The NICE guideline includes economic and quality-of-life evidence in their recommendations while AAN and SIGN do not. In these regards, current data fails to show superiority for newer agents.
In the past 5 years, several CPGs have been published in epilepsy management. Only 3 guidelines have explicit recommendations for initial pharmacological treatment of adults with epilepsy. With some variation regarding which medications are recommended from each group, all CPGs promote standard and newer AEDs as having similar clinical efficacy. Until efficacy, quality of life, or cost data for the newer agents demonstrates a superior outcome, older AEDs remain viable options as first-line for monotherapy in newly diagnosed patients and may provide cost benefits over newer agents.
临床实践指南（CPGs）不仅旨在为医疗服务提供者提供支持性信息，还可作为医疗政策决策的指南。然而，现有的临床实践指南并不总是得出相同的结论。本研究的目的是比较已发表的临床实践指南中关于成人新发癫痫初始药物治疗的建议。
我们对2000年1月至2005年6月期间由著名国家组织发表的关于成人癫痫初始药物治疗的临床实践指南进行了系统评价。
共确定了5份临床实践指南和1份证据报告，其重点是癫痫的药物治疗管理。与成人新发癫痫治疗问题最相关的3份指南分别由美国神经病学学会（AAN）、苏格兰校际指南网络（SIGN）和国家卫生与临床优化研究所（NICE）制定。美国神经病学学会建议在新诊断的癫痫中使用最近引入的抗癫痫药物（AEDs：加巴喷丁、拉莫三嗪、托吡酯和奥卡西平）和标准药物（卡马西平、苯妥英、丙戊酸/丙戊酸钠和苯巴比妥），即非分层方法。或者，国家卫生与临床优化研究所建议仅在对 older agents 无获益的患者中使用更新的抗癫痫药物（拉莫三嗪、托吡酯和奥卡西平）——一种分层方法。苏格兰校际指南网络指出，所有获准用于单药治疗的抗癫痫药物在新诊断的癫痫中具有相似的疗效——这是一种非分层方法的建议。更新的抗癫痫药物（拉莫三嗪和奥卡西平）与标准药物（卡马西平和丙戊酸/丙戊酸钠）一样被推荐作为一线初始治疗。国家卫生与临床优化研究所的指南在其建议中纳入了经济和生活质量证据，而美国神经病学学会和苏格兰校际指南网络则没有。在这些方面，目前的数据未能显示更新药物的优越性。
在过去5年中，已发表了几份关于癫痫管理的临床实践指南。只有3份指南对成人癫痫的初始药物治疗有明确建议。尽管每组推荐的药物有所不同，但所有临床实践指南都认为标准和更新的抗癫痫药物具有相似的临床疗效。在更新药物的疗效、生活质量或成本数据显示出更好的结果之前， older AEDs 仍然是新诊断患者单药治疗一线的可行选择，并且可能比更新药物具有成本效益。
