Strategies to prevent overtreatment with antiepileptic drugs in patients with epilepsy

Abstract

Overtreatment is defined here as an unnecessary and excessive drug load in the management of epilepsy leading to a suboptimal risk-to-benefit balance. Pharmacological overtreatment can often be prevented by deciding and counselling carefully about the need for antiepileptic drugs (AEDs) given the limitations of current AEDs. Although AEDs will reduce the incidence of seizures, they have no demonstrated ability to prevent epilepsy in patients at risk or to modify the course of epilepsy in patients following the first seizure. In addition, starting AEDs may not be necessary for control of epileptic seizures induced by precipitation or predisposing factors or for benign epilepsies with rare or mild seizures. Start monotherapy with the chosen first-line AED, initially at low doses titrating up to the low maintenance dose. Avoid drug loading (except for emergency treatment). If seizures continue, titrate to the limit of tolerability which will however, achieve additional seizure control in approximately 20% of patients. If, as in many patients, dosing to the limit of tolerability is not beneficial, the dose should be reduced. Switching to an average dose of another first line AED is another option to prevent overtreatment. Avoid drug overload during add-on therapy by slowly reducing the dose of the first drug in patients having adverse effects, ideally by an amount that the patient does not experience any further adverse effects, if possible, before adding another drug. If the patient does not benefit unequivocally from two-drug therapy within 3 months (and approximately 75% will not benefit), slowly transfer to monotherapy of the second drug and start with a newly chosen AED for add-on. To counteract the propensity to overmedication in chronic epilepsy is not easy. Great benefits, without loss of seizure control, are often gained by slowly reducing the overall drug load.

Introduction

Overtreatment may occur at all stages of antiepileptic drug (AED) treatment, starting from primary prophylaxis in people at risk for epilepsy, treating single or rare seizures, and those with early or chronic epilepsy (Table 1). Although the percentage of patients exposed to the various forms of overtreatment can only be assessed in retrospective studies of biased cohorts, a conservative estimate is that as many as 30% of patients with refractory epilepsy may be either misdiagnosed, or overtreated with unnecessary drug load (Schmidt, 2000, Walker and Sander, 1994, Schmidt et al., 2002). If not corrected, overtreatment may cause significant, even serious adverse events and waste resources. Given the fact that epilepsy is one of the most common disorders in neurology, affecting as much as 1–2% of the population, overtreatment is a major public health issue. Thus, new concepts and original ideas for preventing overtreatment are urgently needed. Overtreatment has recently been defined as unnecessary and excessive drug load in the management of epilepsy leading to a suboptimal risk-benefit balance (Schmidt et al., 2002). This overview discusses strategies for prevention of overtreatment in epilepsy. The recommendations should not be taken as a rigid blueprint for medical practice for each patient with epilepsy. Instead they suggest general management principles and suggestions based on the best clinical evidence available.

Be aware of overtreatment. It may occur at every level of AED use. Before starting medical treatment, increasing the dose, or adding another AED, make sure the drug load is needed.