Practice Uncertainties Page

What is the optimal management of partial epilepsy uncontrolled by a first choice anticonvulsant?

BMJ 2008; 337 doi: (Published 14 November 2008) Cite this as: BMJ 2008;337:a2199
  1. David W Chadwick, emeritus professor of neurology1,
  2. Gus A Baker, professor of neuropsychology1,
  3. Ann Jacoby, research professor, Division of Public Health1,
  4. Anthony G Marson, reader in neurology1,
  5. Phil E Smith, consultant and honorary professor2
  1. 1University of Liverpool, Walton Centre, Liverpool L9 7LJ
  2. 2University Hospital of Wales, Cardiff CF14 4XW
  1. Correspondence to: D W Chadwick d.w.chadwick{at}
  • Accepted 25 March 2008

Up to 70% of people who are treated with a single anticonvulsant will enter remission within a short time of being diagnosed with epilepsy.1 Optimal first choice treatments have been identified in some comparative randomised controlled trials and guidelines from the National Institute for Health and Clinical Excellence.2 3 Lamotrigine or carbamazepine are usually the preferred initial treatment of seizures with localised onset in the brain, whereas valproate is preferred for generalised epilepsy syndromes.4 5

However, despite optimal doses of a first line anticonvulsant, many patients with localised onset seizures (10-15/100 000 each year worldwide) do not enter remission and continue to have seizures of varying severity and frequency, which are associated with considerable psychosocial distress.6 7 The evidence base to support management of these patients is minimal,2 and it is uncertain which of the following available options is optimal:

  • Continue with the existing first line treatment as monotherapy.

  • Switch to …

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