Monostars: An aid to choosing an antiepileptic drug as monotherapy

This article describes a flexible, dynamic system for comparing antiepilept ic drugs (AEDs) as monotherapy, taking into account the needs of the patien t and the characteristics of the treatment. Because differences in efficacy between AEDs cannot readily be demonstrated in regulatory clinical trials, safety is of paramount importance. Each drug has been judged across 11 cri teria. These include knowledge of mechanism of action, suitable pharmacokin etics, drug interactions, delineated range of efficacy, ease of titration, idiosyncratic reactions, sedative burden, neuropsychiatric profile, teratog enic potential, and the likelihood of producing long-term side effects. The final consideration relates to how "comfortable" the doctor is with prescr ibing the drug as monotherapy. Scores of -1 (drawback), 0 (neutral/unknown) , or +1 (advantage) have been allocated under each category, depending on c urrent knowledge and clinical experience. The sum of the individual scores determines the awarding of "stars." In addition, the positive and negative features of each AED, when used as monotherapy, are highlighted. A range of established and new AEDs has been examined using the "monostars" method, i ncluding phenobarbital, phenytoin, carbamazepine, sodium valproate, lamotri gine, gabapentin, oxcarbazepine, and vigabatrin, Scores can be adjusted as new information comes to light. Other agents can be added when suitable mon otherapy da;a become available. This analysis supports the contention that choice of treatment in newly diagnosed epilepsy should take into considerat ion the patient's age, sex, general health, coexisting disabilities, concom itant medication, and life style. Seizure type, syndrome, and the AED's pha rmacology, efficacy, and safety profile should also be considered. Because dosing is often modest, cost should rarely be the overriding factor in choo sing a drug for a patient with newly diagnosed epilepsy in the developed wo rld. With these criteria, some of the newer AEDs have potentially more to o ffer the patient as monotherapy than do the established agents.