Low vs. Standard Daily Doses of Antiepileptic Drugs in Newly Diagnosed, Previously Untreated Epilepsy(STANDLOW)

Study Overview
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Brief Summary
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There are no guidelines on the first maintenance daily dose of antiepileptic drugs (AEDs) in newly diagnosed, previously untreated epilepsy. Original trials and Cochrane reviews show that seizure remission can be achieved with differing daily doses. In clinical practice, the first maintenance dose varies significantly. In contrast, the risk of adverse treatment effects increases with dosage. There is thus the need to identify the lowest effective dose for treatment start. This background prompted us to undertake a randomized multicenter pragmatic non-inferiority trial comparing standard to low daily doses of AEDs to demonstrate that low doses are at least as effective as standard doses (as indicated by the national formulary) but are better tolerated and are associated with a better quality of life. If proven as effective as the standard dose, a low daily dose of AEDs is a benefit to the patient in terms of tolerability and safety and a source of savings for the National Health System.

Official Title
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Efficacy and Tolerability of Low vs. Standard Daily Doses of Antiepileptic Drugs in Newly Diagnosed, Previously Untreated Epilepsy (STANDLOW). A Multicenter, Randomized, Single-blind, Parallel-group Trial

Conditions
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Epilepsies, Partial

Intervention / Treatment
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* Drug: Low dose carbamazepine
* Drug: Standard dose carbamazepine
* Drug: Low dose levetiracetam
* Drug: Standard dose levetiracetam
* Drug: Low dose valproate
* Drug: Standard dose valproate
* Drug: Low dose zonisamide
* Drug: Standard dose zonisamide
* Drug: Low dose oxcarbazepine
* Drug: Standard dose oxcarbazepine
* Drug: Low dose topiramate
* Drug: Standard dose topiramate
* Drug: Low dose lamotrigine
* Drug: Standard dose lamotrigine
* Drug: Low dose gabapentin
* Drug: Standard dose gabapentin


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age 18 years or older; Newly diagnosed previously untreated epilepsy, defined according to the ILAE definition (Fisher et al, 2014); Having experienced focal seizures, defined according to the ILAE criteria (Commission, 1981); Able to understand and comply with the study requirements and release a written informed consent. Exclusion Criteria: A patient will be excluded if at least one of the following criteria will be met: Age less than 18 years; Having experienced primarily or secondarily generalized tonic and/or clonic seizures, or other (non-focal) seizure types; Previous exposure to AEDs; Requiring low or standard doses on account of individual needs; Inability to understand the aims or modalities of the study; Current pregnancy or planning to become pregnant during the study period (e.g. who are not post-menopausal, surgically sterile, or using inadequate birth control). A postmenopausal state is defined as no menses for 12 months without an alternative medical cause; Previous treatment with an antiepileptic drug; Men unable to practice contraception for the duration of the treatment. Poor compliance with assigned treatments; Refusal to release written informed consent; The study investigators will receive the summary of product characteristics (SPC) available for each study drug. Patients cannot be enrolled in the study if the contraindications/warnings described in the SPC are met.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: This is a multicenter randomized pragmatic parallel-group single-blind non-inferiority trial.
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Low dose<br>Dosage is in mg: low dose carbamazepine, 300 ; low dose levetiracetam, 500; low dose valproate, 300; low dose zonisamide, 150; low dose oxcarbazepine, 600; low dose topiramate, 100; low dose lamotrigine, 100; low dose gabapentin, 450. Study drugs are in form of tablets for daily administration. Study drug administration duration is 12 months. The choice of the drug is left to the caring physician's discretion but it must be limited to the AEDs marketed for monotherapy use. All the study drugs will be used according to the respective SPCs, which will be sent by the promoter to all the study investigators. | Drug: Low dose carbamazepine<br>* Carbamazepine, 300 mg/die<br>* Other names: low carbamazepine;Drug: Low dose levetiracetam<br>* Levetiracetam 500 mg/die<br>* Other names: Low levetiracetam;Drug: Low dose valproate<br>* Valproate 300 mg/die<br>* Other names: Low valproate;Drug: Low dose zonisamide<br>* Zonisamide 150 mg/die<br>* Other names: Low zonisamide;Drug: Low dose oxcarbazepine<br>* Oxcarbazepine 600 mg/die<br>* Other names: Low oxcarbazepine;Drug: Low dose topiramate<br>* Topiramate 100 mg/die<br>* Other names: Low topiramate;Drug: Low dose lamotrigine<br>* Lamotrigine 100 mg/die<br>* Other names: Low lamotrigine;Drug: Low dose gabapentin<br>* Gabapentin 450 mg/die<br>* Other names: Low gabapentin;|
| Active Comparator: Standard dose<br>Dosage is in mg: standard dose carbamazepine 600; standard dose levetiracetam 1000; standard dose valproate, 600; standard dose zonisamide 300; standard dose oxcarbazepine 1200; standard dose topiramate, 200; standard dose lamotrigine, 200; standard dose gabapentin 900. Study drugs are in form of tablets for daily administration. Study drug administration duration is 12 months. The choice of the drug is left to the caring physician's discretion but it must be limited to the AEDs marketed for monotherapy use. All the study drugs will be used according to the respective SPCs, which will be sent by the promoter to all the study investigators. | Drug: Standard dose carbamazepine<br>* Carbamazepine 600 mg/die<br>* Other names: Standard carbamazepine;Drug: Standard dose levetiracetam<br>* Levetiracetam 1000 mg/die<br>* Other names: Standard levetiracetam;Drug: Standard dose valproate<br>* Valproate 600 mg/die<br>* Other names: Standard valproate;Drug: Standard dose zonisamide<br>* Zonisamide 300 mg/die<br>* Other names: Standard zonisamide;Drug: Standard dose oxcarbazepine<br>* Oxcarbazepine 1200 mg/die<br>* Other names: Standard oxcarbazepine;Drug: Standard dose topiramate<br>* Topiramate 200 mg/die<br>* Other names: Standard topiramate;Drug: Standard dose lamotrigine<br>* Lamotrigine 200 mg/die<br>* Other names: Standard lamotrigine;Drug: Standard dose gabapentin<br>* Gabapentin 900 mg/die<br>* Other names: Standard gabapentin;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Treatment failure | The proportion of patients experiencing a treatment failure motivated by the need to change the assigned dose or the assigned drug for seizure relapse during the follow-up. | 12 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Drug-related adverse events | the proportion of patients experiencing a treatment failure motivated by intolerable drug-related adverse events during the follow-up; | 12 months | 
| Quality of life in epilepsy scale 31 items(QOLIE-31), italian version | QOLIE-31 total score at baseline and last visit. Maximum total score is 100 (best quality of life possible) and the minimum is 0 (worst quality of life possible). | 12 months | 
| Patients health care's satisfaction (PSQ-18) scale, 18 items | The score of the seven PSQ-18 subscales (general satisfaction, technical quality, interpersonal manner, communication, financial aspects, time spent with doctor, accessibility and convenience) at baseline and last visit. Possible scores of each subscale range from 1 (worst satisfaction) to 5 (better satisfaction). There is no total score for this scale. | 12 months | 
| Health care resources utilization. | The mean daily patient's cost of health care resources consumed for the management of epilepsy during the first 12 months of the study. | 12 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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epilepsy, antiepileptic drugs, low dose, standard dose, new diagnosis