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Title: The pharmacological treatment of epilepsy in adults.
Austin Authors: Tomson, Torbjörn;Zelano, Johan;Dang, Yew Li;Perucca, Piero 
Affiliation: Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, Gothenburg, Swet of Neurology, Sahlgrenska den.;DepartmenUniversity Hospital, Gothenburg, Sweden.;Wallenberg Center of Molecular and Translational Medicine, Gothenburg University, Gothenburg, Sweden.
Comprehensive Epilepsy Program
Epilepsy Research Centre, Department of Medicine (Austin Health), The University of Melbourne, Melbourne, Victoria, Australia.;Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.;Department of Neurology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.;Department of Neurology, Alfred Health, Melbourne, Victoria, Australia.
Medicine (University of Melbourne)
Issue Date: 29-Jun-2023
Date: 2023
Publication information: Epileptic Disorders : International Epilepsy Journal with Videotape 2023-06-29
Abstract: 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.
DOI: 10.1002/epd2.20093
ORCID: 0000-0003-0554-5352
Journal: Epileptic Disorders : International Epilepsy Journal with Videotape
PubMed URL: 37386690
ISSN: 1950-6945
Type: Journal Article
Subjects: antiseizure medication
Appears in Collections:Journal articles

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