[Dilemmas of contemporary epilepsy pharmacotherapy]

The last decade was characterized by an enormous progress in all fields of epilepsy. The availability of a relatively great number of drugs that can be categorized into standard and new antiepileptic drugs (AEDs) has made individualization of therapy possible, but has challenged the clinician to answer many questions in everyday clinical routine that are not even theoretically satisfactorily solved. Among other questions, it refers to the choice of the most appropriate AED for specific therapeutic situations. Certainly, clinical trials that are harmonized with the principles of evidence-based medicine (EBM) constitute the basis for the evaluation of AEDs. In the forming of value judgments concerning new AEDs, the most influential were clinical trials with these drugs tested as add-on therapy in pharmacoresistant epilepsy. However, many relevant clinical questions have remained unanswered by these studies, primarily because the design of these trials was more appropriate for the licensing of new drugs than for clinical practice. As far as such a complex clinical condition as epilepsy is concerned, it is difficult to define the design for clinical drug trials that might be considered generally acceptable. Nevertheless, randomized controlled studies in newly diagnosed epilepsy, where the main outcome variable is the seizure absence, constitute the main methodological standard. The disproportion between the enormous quantity of easily accessible information about epilepsy therapy and the individual capability to meaningfully process that information is certainly one of the main challenges faced by a clinician. One of the solutions offered lately by some respectable professional organizations might be the implementation of treatment guidelines made on the basis of available studies that satisfy the standards of EBM. It can be assumed that the existing guidelines, and the guidelines that are yet expected, will be very influential. However, there is a prevailing consensus that therapy should be definitely individualized. Based on the contemporary level of knowledge, it means that it should be the result of dynamic interaction between the seizure type and epileptic syndrome, specific features of AEDs, and individual characteristics of the patient.