Positive aspects SANAD

This year saw the publication of the SANAD study, published as 2 papers in the Lancet by Marson et al. [1,2]. The SANAD study consisted of 2 arms. In arm A1, the effectiveness of carbamazepine, taken as the standard treatment for partial onset seizures, was compared to that of 4 other anti-epileptic drugs, gabapentin, lamotrigine, oxcarbazepine and topiramate. One thousand seven hundred and twenty-one patients were recruited and randomly assigned to one of the treatments. Primary outcome measures, the same for both arms of the study, were time to treatment failure (withdrawal of the randomised drug for reasons of unacceptable adverse events or inadequate seizure control or a combination of the two) and time to achieve a 12-month remission. Lamotrigine had the lowest treatment failure rates and was statistically superior to all drugs in this regard except oxcarbazepine. The superiority of lamotrigine over carbamazepine was based on its apparant better tolerability but there was evidence that lamotrigine was not inferior to carbamazepine in measures of efficacy. Based on these findings, the authors recommend that lamotrigine is a cost-effeective alternative to carbamazepine and should replace it as standard treatment for patients with partial onset epilepsy. However, it should be noted that the differences in the drugs was slight – and a more striking conclusion is the similarity in outcome rather than the difference. In the second arm of the study [2], the effectiveness of the accepted standard treatment for generalised onset or unclassified seizures sodium valproate, was compared with that of lamotrigine and topiramate. Seven hundred and sixteen patients were recruited and randomly assigned to one of the treatment arms. Primary outcome measures were as before. Valproate was significantly better tolerated than topiramate For time to treatment failure, valproate was superior to both topiramate and lamotirigine. Valproate was the least likely to be associated with treatment failure due ro inadequate seizure control and most likely to achieve a 12-month remission. Based on these results, the authors recommend that sodium valpraote remain the standard treatment of generalised onset and unclassified seizures. We will examine the positive aspects and criticisms of the study.