[Treatment protocol for long-term anti-epilepsy drugs in adults with refractory partial epilepsy]

The primary goals of antiepileptic treatment are complete cessation of seizure without any adverse reaction. In adult refractory focal epilepsies, a rational approach is based on adequate syndromic categorization and accurate knowledge of the pharmacological properties of antiepileptic drugs, whose number has significantly increased in recent years. Since 1991 nine new antiepileptic medications have been marketed in France, i. e. by order of appearance, vigabatrin (Sabril), felbamate (Taloxa), gabapentin (Neurontin), lamotrigine (Lamictal), tiagabine (Gabitril), fosphenytoin (a water-soluble phenytoin prodrug, Prodilantin), topiramate (Epitomax), oxcarbazepine (Trileptal) and levetiracetam (Keppra). Efficacy of these new compounds in focal epilepsies is proven, and in some patients with middle-severity focal epilepsy, clinical benefit is significant. Improvement is especially significant in terms of tolerability, ease of use and reduced interaction potential. However, some of these drugs (tiagabine, topiramate) may have an unfavorable short-term tolerance profile, while others (felbamate, lamotrigine) expose patients to a potential risk of severe acute idiosyncratic reactions. Increased availability of new drugs and the fact that drug monitoring has been claimed to be of little or no value in newly-marketed drugs have paradoxically strongly complicated therapeutic options. Moreover, only a few patients with truly refractory focal epilepsy can be made seizure-free by these new compounds, and the search for more effective anticonvulsants should continue in addition with alternative therapies or surgery.