Antiepileptic drug therapy: general treatment principles and application for special patient populations

Over the past 10 years, the goal of treating epilepsy has evolved from attaining complete control of seizures, regardless of medication-related side effects or psychosocial problems, to enabling the patient to lead a lifestyle consistent with his or her capabilities. The recent introduction of new medications has brought hope to patients who have previously been unable to function optimally because of refractory seizures or side effects. A rational approach to selecting antiepileptic drug (AED) therapy for a particular patient would require a detailed understanding of the underlying cause(s) of seizures in that patient. Unfortunately, this is often not possible. Furthermore, currently available AEDs have been tested on the basis of seizure type rather than etiology. Nevertheless, an individualized empirical approach based on an open dialog with the patient and perseverance is often successful. There have also been significant advances in the understanding of seizures at the cellular level, notably in the role of gamma-aminobutyric acid. Medical, social, and psychosocial issues relevant to particular patient populations (such as women of childbearing age and elderly patients) also must be considered when treatment plans are formulated. The recent addition of new AEDs, with unique mechanisms of action and favorable pharmacokinetic and tolerability profiles, has greatly widened the range of therapeutic options for patients.