Efficacy, tolerability, and neuropsychological effects of ethosuximide, valproic acid, and lamotrigine in children with newly diagnosed childhood absence epilepsy were compared in a double-blind, randomized, controlled clinical trial performed at six centers in the US and organized as a Study Group. Drug doses were incrementally increased until freedom from seizures or highest tolerable dose was reached, Primary outcome was freedom from treatment failure after 16 weeks therapy, and secondary outcome was attentional dysfunction. In a total of 453 children, the freedom-from-failure rates after 16 weeks were similar for ethosuximide (53%) and valproic acid (58%), and higher than the rate for lamotrigine (29%) (P<0.001). Attentional dysfunction was more common with valproic acid (49%) than with ethosuximide (33%) (P=0.03). [1]

COMMENT. “Older is better,” is the conclusion of Vining EPG, in an editorial [2]. As generally accepted in US practice and confirmed by the above controlled trial, ethosuximide from the 1950s is the optimal initial therapy for childhood absence epilepsy without GTCS. Ethosuximide is equal to valproic acid in seizure control and superior in effects on attention. Attentiveness was significantly poorer among children receiving valproic acid than in those taking ethosuximide or lamotrigine, an important factor in the choice of long-term therapy for epilepsy in children.