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Treating refractory epilepsy in adults

BMJ 2006; 332 doi: (Published 09 March 2006) Cite this as: BMJ 2006;332:562

This article has a correction. Please see:

  1. Edward Reynolds, honorary senior lecturer (
  1. Institute of Epileptology, King's College, London SE5 6PJ

    The choice of drug or drug combinations is bewildering

    Most adult patients with refractory epilepsy have partial (focal) seizures with or without secondary generalisation. During the 1970s and early 1980s studies showed that in 70-80% of adults with newly diagnosed epilepsy, seizures were controlled successfully by carefully monitored monotherapy with any of the four standard antiepileptic drugs—phenobarbital, phenytoin, carbamazepine, or sodium valproate—all of which seemed to have similar efficacy in partial epilepsy in later comparative trials of monotherapy.14 Furthermore, adding a second drug for patients with continuing seizures on optimum monotherapy led to modest benefit in no more than one third, a deterioration in seizure control or unacceptable toxicity in about a quarter, and no change in the rest.2 5

    These studies led to important questions. Should patients unresponsive to the optimum use of the first drug be switched to alternative monotherapy or treated with polytherapy? If so, …

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