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Patients with newly diagnosed epilepsy and their doctors have a bewildering choice of first line drugs. Navigating through them just got slightly easier with the publication of a large trial comparing the main choices head to head. Lamotrigine emerged as the best choice for patients with partial seizures, and valproate had the most favourable profile for patients with generalised or unclassified seizures.
The results are simple and satisfying, says a linked comment (pp 970-1). The trial was completely independent of the drugs industry, had a reasonably long follow-up, and should give doctors much needed focus. Lamotrigine will soon be off patent, and valproate is already cheaper than newer alternatives, so even those who pick up the bill should be happy.
The author warns, however, that there's no such thing as “one size fits all” in epilepsy. For example, concerns exist about the safety of lamotrigine and valproate in women who might get pregnant. Valproate causes weight gain, an important consideration for some patients, and has been linked to altered platelet counts and rare but life threatening pancreatitis. These and other considerations mean that doctors must still match the drug to the patient. But at least they now know where to start.