Novel antiseizure drugs as first-line treatment

Wieslaw Oczkowski, MD, is a professor emeritus in the Department of Medicine at McMaster University and director of the Regional Stroke Network for the Central South Ontario Region.

Novel antiseizure drugs are typically approved as adjunctive therapy, to be used as an add-on. It might take years until their registration is expanded to include initial monotherapy. Do you think that cenobamate and other novel drugs could reduce the rates of drug resistance when introduced earlier, even as first-line medications in selected patients?

The primary reason why almost all medications that are released for seizure management are add-on treatment is that the models of seizure that are used to develop these medications are from a focal lesional model of epilepsy as opposed to a generalized epilepsy model. In many ways the patients that are in the randomized clinical trials are also patients with most likely nongeneralized epilepsy, with more focal epilepsy, and the treatments are always added to other treatments as a start, in which case we don’t know how they would manage on their own as a beginning.

I think you will find that in the hands of epileptologists—epilepsy experts—very often a newer medication may come on board and if a patient is on other medications the others may be discontinued or decreased with the new medication if it’s very effective. I think we will find in the future that transition to multiple add-on therapy, to monotherapy may be more rapid because of the experience of the past of that same sort of phenomena.