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THE LANCET Neurology Vol 3 May 2004 http://neurology.thelancet.com 261

Newsdesk

The UK National Institute of ClinicalExcellence (NICE) has recommendedthat doctors in England and Walesshould use the newer epilepsy drugsgabapentin, lamotrigine, levetiracetam,oxcarbazepine, tiagibine, topiramate,and vigabatrin to treat epilepsy inadults who have not benefited fromtreatment with older drugs, such ascarbamazepine or sodium valproate.The American Academy of Neurologywill release similar guidelines at itsannual meeting in San Francisco (April24–May 1).

NICE—part of the UK NationalHealth Service set up to provide“authoritative, robust and reliableguidance on current best practice”—have also recommended that thenewer drugs should be given to anypatient who: has any contra-indications while taking or who doesnot tolerate the older drugs; is on anyother medication known to react withthe older drugs, such as oral

contraceptives; or is a woman ofchildbearing age.

The newer drugs, some of whichhave been available for over 10 years,are associated with a better quality oflife, fewer drug interactions, andmore convenient dose regimens.

NICE also recommends thatpatients should be treated withmonotherapy wherever possible. Ifinitial treatment is unsuccessful,monotherapy with an alternative drugshould be tried. Combination therapyshould only be an option whentreatment with monotherapy hasfailed to prevent seizures.Lamotrigine, oxcarbazepine, andtopiramate are licensed in the UK foruse as monotherapy; all the drugs arelicensed for use in combinationtherapy.

John Duncan, who was a memberof the development group that helpeddraw up the guidelines, said hewelcomed the fact that NICE and the

NHS were taking epilepsy seriouslyand hoped the guidelines wouldencourage review of new therapies.

However, Duncan, who is based atthe Institute of Neurology, London,UK pointed out that the limitation ofthe guidelines was that theyoversimplified the disorder and didnot fully take into account the“enormous heterogeneity of seizures,epilepsy syndromes, and individualpatient factors such as age, lifestyle,and comorbidity”.

Carl Bazil, Associate Professor ofClinical Neurology (ColumbiaUniversity, NY, USA) told TheLancet Neurology that the NHSguideline was very practical, accurate,and up-to-date and explained that the US guidance would be verysimilar.

NICE are expected to publishfurther guidance on use of the newerdrugs in children later this year.Louise Marshall

Out with the old and in with the new . . . epilepsy drugs

The prevalence of disability afterstroke is similar in South Africa to thatin more affluent countries, despite theprevalence of stroke itself being two orthree times lower than in high-incomecountries.

“We don’t yet know as much as wewould like to about the nature ofstroke on the field site”, says MargaretThorogood (University of Warwick,UK) “but our findings suggest a highproportion of victims are left withdisability.”

Thorogood and researchers for theSouthern African Stroke PreventionInitiative (SASPI) studied 42 378people age >15 years in the deprivedrural Agincourt sub-district ofLimpopo Province in South Africa.103 survivors of stroke were identified;after correction for missing data, thecrude prevalence of stroke was 300 per100 000 people (Stroke 2004; 35:627–32). Two-thirds of the survivorsof stroke needed help with at least oneactivity of daily living; in moredeveloped countries only a fifth ofsurvivors of stroke have disability.

“This research shows that globalhealth epidemiology is changing, withmore stroke burden being placed inlow income, less developed countries”,says Valery Feigin (University ofAuckland, New Zealand).

These population-specific prev-alence data, Feigin explains, allowprecise estimates of rehabilitationservices requirement in South Africa,highlight the need for acute and postacute stroke care, identify promisingpreventive strategies (focusing themanagement of hypertension), andshow the clear need for furtherresearch of stroke incidence and riskfactors, as well as prevention andmanagement stategies of stroke inAfrica.

The differences in stroke outcomeand prognosis between developedcountries and developing countries arelikely determined by the higherproportion of haemorrhagic strokesand the poorer health care indeveloping countries, says Feigin.

SASPI hope their work will help todevelop and test interventions, to learn

more about the nature of stroke, andto track the prevalence ofcardiovascular risk factors in thecommunity. “Our goal”, Thorogoodtold The Lancet Neurology, “is toreduce the burden of cardiovasculardisease in a country already copingwith the huge demands of HIV/AIDSand poverty.”

Myles Connor (University ofWitwatersand, Gauteng Province,South Africa) explains that “theprevalence work is only one componentof the SASPI work”. They have alsoassessed people’s understanding ofillness (specifically stroke) access tohealth care (including traditionalmedicine), and cardiovascular-risk-factor prevalence .

In June this year, WHO, theInternational Stroke Society, andthe World Federation of Neurologywill launch the Global Stroke Initiativeto develop stroke surveillance, pre-vention, and control with a focus onmiddle-income and low-incomecountries.Peter Hayward

Stroke disability in South Africa matches more affluent nations