Title: A Systematic Review of Monotherapies for Epilepsy Complicated by Drop Attacks

Author: David Blihar, MD; Igor Khvylia; Serena Strollo-DiCenso, BA; Savannah Seeger, BS; Talha Khan; Hanish Polavarapu, MS; Helena Bui, BS; Sunny Korsapati, BS; David Gemmel, PhD; Randall Waechter, PhD

Email: dblihar@mercy.com

Introduction: Atonic (i.e., akinetic or drop) seizures occur with a sudden, short duration loss of muscle tone and consciousness and must be treated without delay because of the possibility of significant patient injury. First-line therapies include anti-epileptic drugs (AEDs) and best clinical practice is to start with a single AED (i.e., monotherapy) and monitor closely for adverse side effects and efficacy. The current study aims to determine which AED monotherapy is most effective in decreasing drop attack incidence.

Discussion of Literature Review: A systematic literature review and meta-analysis were carried out on all studies examining monotherapy AED regimens in epileptic patients presenting with atonic seizures. To be selected, articles had to: (1) Include patients with epilepsy complicated by atonic seizures; (2) Demonstrate a monotherapy pharmacological intervention of vigabatrin, valproate, divalproex, clonazepam, levetiracetam, lamotrigine, clobazam, and/or cannabidiol; (3) Report patient outcomes of decreased seizure frequency and decreased frequency of drop attacks. A Chi-Squared analysis was used to calculate a cumulative effect size for seizure reduction difference between AED treatment arms and the mean difference in the numbers of drop attacks between treatment groups. Six studies met inclusion criteria. More patients receiving valproate showed a complete freedom from seizures compared to patients receiving carbamazepine, clobazam, clonazepam, or lamotrigine.

Conclusion: In the present study, valproate emerges as a relatively safe initial therapy considering its effectiveness and tolerability profile. While more data is needed, the current results can be used to inform clinical decision-making in managing this challenging aspect of epilepsy.