TY - JOUR
T1 - The pharmacological treatment of epilepsy in adults
AU - Tomson, Torbjörn
AU - Zelano, Johan
AU - Dang, Yew Li
AU - Perucca, Piero
N1 - Funding Information:
TT reports research support to EURAP, the International Antiepileptic Drugs, and Pregnancy Registry from the following companies: Accord, Angelini, Bial, Eisai, Glenmark, GSK, GW Pharma, Sanofi, Teva, UCB, Zentiva, EcuPharma, and SF Group; and speaker's honoraria to his institution from Angelini, Eisai, GSK, and UCB all outside the submitted work. JZ reports speaker honoraria from UCB and Eisai for non‐branded educations, and as an employee of Sahlgrenska University Hospital being an investigator/sub‐investigator in clinical trials sponsored by GW Pharma, SK life science, UCB, and Bial (no personal compensation). YLD is supported by the National Health and Medical Research Council (NHMRC) (APP2013800) and the University of Melbourne Research Training Program Scholarship. She has received speaker honoraria from Eisai and SEER Medical, outside the submitted work. PP is supported by an Emerging Leadership 2 Investigator Grant from the Australian National Health and Medical Research Council (APP2017651), the Epilepsy Foundation, The University of Melbourne, Monash University, the Weary Dunlop Medical Research Foundation, Brain Australia, and the Norman Beischer Medical Research Foundation. He has received speaker honoraria or consultancy fees to his institution from Chiesi, Eisai, LivaNova, Novartis, Sun Pharma, Supernus, and UCB Pharma, outside the submitted work. He is an Associate Editor for Epilepsia Open.
Publisher Copyright:
© 2023 The Authors. Epileptic Disorders published by Wiley Periodicals LLC on behalf of International League Against Epilepsy.
PY - 2023/10
Y1 - 2023/10
N2 - The pharmacological treatment of epilepsy entails several critical decisions that need to be based on an individual careful risk–benefit analysis. These include when to initiate treatment and with which antiseizure medication (ASM). With more than 25 ASMs on the market, physicians have opportunities to tailor the treatment to individual patients´ needs. ASM selection is primarily based on the patient's type of epilepsy and spectrum of ASM efficacy, but several other factors must be considered. These include age, sex, comorbidities, and concomitant medications to mention the most important. Individual susceptibility to adverse drug effects, ease of use, costs, and personal preferences should also be taken into account. Once an ASM has been selected, the next step is to decide on an individual target maintenance dose and a titration scheme to reach this dose. When the clinical circumstances permit, a slow titration is generally preferred since it is associated with improved tolerability. The maintenance dose is adjusted based on the clinical response aiming at the lowest effective dose. Therapeutic drug monitoring can be of value in efforts to establish the optimal dose. If the first monotherapy fails to control seizures without significant adverse effects, the next step will be to gradually switch to an alternative monotherapy, or sometimes to add another ASM. If an add-on is considered, combining ASMs with different modes of action is usually recommended. Misdiagnosis of epilepsy, non-adherence and suboptimal dosing are frequent causes of treatment failure and should be excluded before a patient is regarded as drug-resistant. Other treatment modalities, including epilepsy surgery, neuromodulation, and dietary therapies, should be considered for truly drug-resistant patients. After some years of seizure freedom, the question of ASM withdrawal often arises. Although successful in many, withdrawal is also associated with risks and the decision needs to be based on careful risk–benefit analysis.
AB - The pharmacological treatment of epilepsy entails several critical decisions that need to be based on an individual careful risk–benefit analysis. These include when to initiate treatment and with which antiseizure medication (ASM). With more than 25 ASMs on the market, physicians have opportunities to tailor the treatment to individual patients´ needs. ASM selection is primarily based on the patient's type of epilepsy and spectrum of ASM efficacy, but several other factors must be considered. These include age, sex, comorbidities, and concomitant medications to mention the most important. Individual susceptibility to adverse drug effects, ease of use, costs, and personal preferences should also be taken into account. Once an ASM has been selected, the next step is to decide on an individual target maintenance dose and a titration scheme to reach this dose. When the clinical circumstances permit, a slow titration is generally preferred since it is associated with improved tolerability. The maintenance dose is adjusted based on the clinical response aiming at the lowest effective dose. Therapeutic drug monitoring can be of value in efforts to establish the optimal dose. If the first monotherapy fails to control seizures without significant adverse effects, the next step will be to gradually switch to an alternative monotherapy, or sometimes to add another ASM. If an add-on is considered, combining ASMs with different modes of action is usually recommended. Misdiagnosis of epilepsy, non-adherence and suboptimal dosing are frequent causes of treatment failure and should be excluded before a patient is regarded as drug-resistant. Other treatment modalities, including epilepsy surgery, neuromodulation, and dietary therapies, should be considered for truly drug-resistant patients. After some years of seizure freedom, the question of ASM withdrawal often arises. Although successful in many, withdrawal is also associated with risks and the decision needs to be based on careful risk–benefit analysis.
KW - antiseizure medication
KW - epilepsy
KW - pharmacotherapy
UR - http://www.scopus.com/inward/record.url?scp=85164604727&partnerID=8YFLogxK
U2 - 10.1002/epd2.20093
DO - 10.1002/epd2.20093
M3 - Article
C2 - 37386690
AN - SCOPUS:85164604727
SN - 1294-9361
VL - 25
SP - 649
EP - 669
JO - Epileptic Disorders
JF - Epileptic Disorders
IS - 5
ER -