A recent review of phenobarbital for the treatment of epilepsy draws attention to an ethical dilemma and to the many gaps in our knowledge about a drug that has been in use since 1912.1 Phenobarbital is commonly prescribed in the developing world, but in most developed countries it has fallen into disrepute. The World Health Organization (WHO) recommends it as a first line drug for partial and generalised tonic-clonic seizures in developing countries.2 Its antiepileptic efficacy is undisputed, but concerns remain about its side effects.1 If people with epilepsy in Britain are not prescribed phenobarbital because of its toxicity, is it ethical to recommend its use in developing countries? And if the drug is not as toxic as it is believed to be, might it not be used more in the developed world?

Phenobarbital has many favourable features: broad spectrum efficacy against all seizure types other than absences; a starting dose within the clinically effective range; seizure freedom rates comparable to those associated with modern drugs; a very low risk of life threatening adverse effects; linear pharmacokinetics; long half life compatible with once daily dosing; low propensity to be a target for drug interactions (except for the inhibition of its …