Pharmacological overtreatment in epilepsy: mechanisms and management

Despite considerable advances in the drug treatment of epilepsy in the last decade, pharmacoresistant epilepsy continues to occur today in as many as one in three patients with newly diagnosed epilepsy. These limitations of current drug treatment may result in the inadvertent overtreatment of patients with epilepsy. Overtreatment is defined here as unnecessary and excessive drug load in the management of epilepsy leading to a suboptimal risk-to-benefit balance. Pharmacological overtreatment is relatively common and may occur at all stages of epilepsy therapy. Scenarios for overtreatment include the unnecessary use of AEDs for prevention of epilepsy in patients at risk where current medications have not been shown to be effective or in patients with benign epilepsy syndromes with mild and rare partial seizures. Unnecessary rapid titration leading to overtreatment is a common occurrence in many patients. In addition, dose titration to the limit of tolerability and polytherapy are of limited utility and thus may cause overtreatment in many patients. As no markers currently exist for prediction of individual drug effect, trial and error still prevail in the pharmacotherapy of epilepsy. The increased drug load needs to be reversed once the risk-to-benefit balance worsens in the eye of the patient and in the assessment of the physician. Informing the patient about the benefit and the limitation of the planned change in medication is important. Because of emerging concern that drug overload may cause significant and even serious adverse effects without adequate benefit in seizure control, more data from rigorous scientific studies and new concepts for early recognition, reduction and prevention of overtreatment are needed.