Abstracts

Rationale: Overall, primary generalized epilepsy shows favorable therapeutic response to multiple antiepileptic drugs, but some may remain resistant. Valproate is typically considered the first line of treatment for idiopathic generalized epilepsy. In many patients however, it is avoided based on its side effect profiles. In other patients it may not result in complete control even in combination with other medications including Lamotrigine and Topiramate. In 6 of our patients with uncontrolled seizures who failed monotherapy on these medications or as a combination with other anti- epileptic drugs (AED), we tried the combination of Lamotrigine and Topirimate in hopes that the therapy would offer fewer side effects and achieve complete seizure control. Methods: We report six patients from our clinic (5 females and 1 male) between ages 20 and 44 with historical and electroencephalographic evidence of primary generalized epilepsy. One patient had generalized tonic clonic (GTC), myoclonic and absence seizures, and two had GTC and myoclonic seizures and three had GTC alone. Two had unacceptable side effects from valproate (33%) and four (67%) patients were on multiple combinations with, topiramate, valproate lamotrigine or Keppra without adequate control prior to switching. Results: Since being placed on the combination of lamotrigine and topiramate, all six (100%) patients have remained seizure free for an average of 2 years (range 2 months to 4 years), although 50% of them continue to have interictal discharges on EEG. Two of the patients are still being tapered off Keppra while the others are on only those two medications. The discontinuation of valproate resulted in a marked reduction of side effects in the two patients. It is interesting to note that one patient was fully controlled on this combination but developed cognitive changes from topiramate. As it has a similar mechanism of action, we switched to zonisamide and the patient remained seizure free. Conclusions: The combination of lamotrigine and Topiramate for patients with intractable primary generalized epilepsy is not well documented in the literature. We report four patients who were poorly controlled despite different combinations of AEDs but became completely controlled with the combination of lamotrigine and Topimarate. Two other patients with intolerable side effects on valproate were switched to this combination also with complete control. We suggest that this combination be considered early on in the treatment of patients for whom the side effect profile of valproate is unacceptable (particularly common in women) or for those who are poorly controlled.