Antiepileptic drug monotherapy for epilepsy in the elderly: A systematic review and network meta‐analysis

Objective To estimate the comparative efficacy and safety of antiepileptic drugs ( AED s) in the elderly with new‐onset epilepsy. Methods We searched electronic databases for randomized controlled trials ( RCT s) of monotherapy AED s to treat epilepsy in elderly. The following outcomes were analyzed: seizure freedom and withdrawal from the study for any cause at 6 and 12 months; withdrawal from the study for any adverse event ( AE ) at 12 months; and occurrence of any AE at 12 months. Effect sizes were estimated by network meta‐analyses within a frequentist framework. The hierarchy of competing interventions was established using the surface under the cumulative ranking curve ( SUCRA ) and mean ranks. Results Five RCT s (1425 patients) were included. Included AED s were carbamazepine immediate‐ and controlled‐release ( CBZ ‐ IR , CBZ ‐ CR ), gabapentin ( GBP ), lacosamide ( LCM ), lamotrigine ( LTG ), levetiracetam ( LEV ), phenytoin ( PHT ), and valproic acid ( VPA ). At the pairwise and network meta‐analyses, there were no differences in any of the comparison according to 6‐ and 12‐month seizure freedom. The treatment with CBZ ‐ IR and CBZ ‐ CR was associated with a higher risk of withdrawal than LTG , LEV , or VPA , and CBZ ‐ IR had the overall highest probability of discontinuation across all AED s. According to SUCRA , the following had the greatest likelihood ranking best for seizure freedom at 6 and 12 months: LCM, LTG, and LEV. CBZ ‐ CR and CBZ ‐ IR had the highest probabilities of being worst for the 12‐month retention. CBZ ‐ IR , CBZ ‐ CR, and GBP had the highest probabilities of withdrawal from the study for AE s, , and VPA had the highest probability of being the best‐tolerated option. Significance Although no significant difference in efficacy was found across treatments, LCM , LTG , and LEV had the highest probability of ranking best for achieving seizure freedom. CBZ ‐ IR and CBZ ‐ CR showed a poor tolerability profile, leading to higher withdrawal rates compared to LEV and VPA .