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Ethosuximide, valproic acid, and lamotrigine in childhood absence epilepsy Glauser TA, Cnaan A, Shinnar S, Hirtz DG, Dlugos D, Masur D, Clark PO, Capparelli EV, Adamson PC; Childhood Absence Epilepsy Study Group. N Engl J Med . 2010 Mar 4;362(9):790-9. doi:10.1056/NEJMoa0902014. PMID: 20200383 https://pubmed.ncbi.nlm.nih.gov/20200383 Background: Childhood absence epilepsy, the most common pediatric epilepsy syndrome, is usually treated with ethosuximide, valproic acid, or lamotrigine. The most efficacious and tolerable initial empirical treatment has not been defined. Methods: In a double-blind, randomized, controlled clinical trial, we compared the efficacy, tolerability, and neuropsychological effects of ethosuximide, valproic acid, and lamotrigine in children with newly diagnosed childhood absence epilepsy. Drug doses were incrementally increased until the child was free of seizures, the maximal allowable or highest tolerable dose was reached, or a criterion indicating treatment failure was met. The primary outcome was freedom from treatment failure after 16 weeks of therapy; the secondary outcome was attentional dysfunction. Differential drug effects were determined by means of pairwise comparisons. Results: The 453 children who were randomly assigned to treatment with ethosuximide (156), lamotrigine (149), or valproic acid (148) were similar with respect to their demographic characteristics. After 16 weeks of therapy, the freedom-from-failure rates for ethosuximide and valproic acid were similar (53% and 58%, respectively; odds ratio with valproic acid vs ethosuximide, 1.26; 95% confidence interval [CI], 0.80 to 1.98; P = .35) and were higher than the rate for lamotrigine (29%; odds ratio with ethosuximide vs lamotrigine, 2.66; 95% CI, 1.65 to 4.28; odds ratio with valproic acid vs lamotrigine, 3.34; 95% CI, 2.06 to 5.42; P < .001 for both comparisons). There were no significant differences among the three drugs with regard to discontinuation because of adverse events. Attentional dysfunction was more common with valproic acid than with ethosuximide (in 49% of the children vs 33%; odds ratio, 1.95; 95% CI, 1.12 to 3.41; P = .03). Conclusions: Ethosuximide and valproic acid are more effective than lamotrigine in the treatment of childhood absence epilepsy. Ethosuximide is associated with fewer adverse attentional effects. (ClinicalTrials.gov number, NCT00088452.)