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NEUROLOGY 2008;70:2171-2178
© 2008 American Academy of Neurology
Contemporary Issues in Neurologic Practice

Trends in antiepileptic drug prescribing for older patients with new-onset epilepsy: 2000–2004

M.J.V. Pugh, PhD, RN, A. C. Van Cott, MD, J. A. Cramer, BS, J. E. Knoefel, MD, M. E. Amuan, MPH, J. Tabares, BA, R. E. Ramsay, MD, D. R. Berlowitz, MD, MPH and Treatment In Geriatric Epilepsy Research (TIGER) team*

From the Department of Veterans Affairs (M.J.V.P.), South Texas Veterans Health Care System VERDICT HSR&D, San Antonio; University of Texas Health Science Center at San Antonio (M.J.V.P., J.T.), Department of Internal Medicine; VA Pittsburgh Healthcare System (A.C.V.C.), Pittsburgh, PA; Yale University (J.A.C.), Department of Psychiatry, West Haven, CT; New Mexico Veteran Health Care System (J.E.K.), Albuquerque; Center for Health Quality, Outcomes and Economic Research (M.E.A., D.R.B.), Bedford VA Hospital, Bedford, MA; and University of Miami School of Medicine (R.E.R.), Miami, FL.

Address correspondence and reprint requests to Dr. Mary Jo Pugh, South Texas Veterans Health Care System (VERDICT), Audie L. Murphy Division (11C6), 7400 Merton Minter Boulevard, San Antonio, TX 78229-4404 PughM{at}uthscsa.edu

Background: Newer antiepileptic drugs (AEDs) have been shown to be equally efficacious as older seizure medications but with fewer neurotoxic and systemic side effects in the elderly. A growing body of clinical recommendations based on systematic literature review and expert opinion advocate the use of the newer agents and avoidance of phenobarbital and phenytoin. This study sought to determine if changes in practice occurred between 2000 and 2004—a time during which evidence and recommendations became increasingly available.

Methods: National data from the Veterans Health Administration (VA; inpatient, outpatient, pharmacy) from 1998 to 2004 and Medicare data (1999–2004) were used to identify patients 66 years and older with new-onset epilepsy. Initial AED was the first AED received from the VA. AEDs were categorized into four groups: phenobarbital, phenytoin, standard (carbamazepine, valproate), and new (gabapentin, lamotrigine, levetiracetam, oxcarbazepine, topiramate).

Results: We found a small reduction in use of phenytoin (70.6% to 66.1%) and phenobarbital (3.2% to 1.9%). Use of new AEDs increased significantly from 12.9% to 19.8%, due primarily to use of lamotrigine, levetiracetam, and topiramate.

Conclusions: Despite a growing list of clinical recommendations and guidelines, phenytoin was the most commonly used antiepileptic drug, and there was little change in its use for elderly patients over 5 years. Research further exploring physician and health care system factors associated with change (or lack thereof) will provide better insight into the impact of clinical recommendations on practice.

GLOSSARY: AED = antiepileptic drug; FDA = Food and Drug Administration; FY = fiscal year; RCT = randomized controlled trial; STVHCS = South Texas Veterans Health Care System; VA = Veterans Health Administration.

Received May 18, 2007. Accepted in final form September 17, 2007.

*Members of the TIGER research team are listed in the appendix.

Funded by VA Health Services Research and Development Service, IIR 02-274 (Dr. Pugh PI). Supported by the South Texas Veterans Healthcare System/Audie L. Murphy Division and the VERDICT research program, along with the Edith Nourse Rogers Memorial VA Medical Center and the Center for Health Quality, Outcomes, and Economic Research, Bedford, MA.

Disclosure: Mary Jo V. Pugh, PhD, RN, research grant from Abbott; Anne C. Van Cott, MD, reports no disclosures; Joyce A. Cramer, BS, is a consultant for Abbott, GlaxoSmithKline, Johnson & Johnson/Ortho-McNeil-Janssen, Marinus, Merck, Pfizer, Roche, SaanofiAventis, UCB; Janice E. Knoefel, MD, reports no disclosures; Megan E. Amuan, MPH, reports no disclosures; Jeffrey Tabares, BA, reports no disclosures; R. Eugene Ramsay, MD, has research grants, serves on advisory committees and speakers bureaus with the following pharmaceutical companies: Pfizer, UCB, Abbott, Johnson & Johnson/Ortho-McNeil-Janssen and GlaxoSmithKline; Dan R. Berlowitz, MD, MPH, reports no disclosures.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.






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