New-onset focal epilepsy in adults: Antiepileptic drug treatment

Focal epilepsy, non-syndromic, is by far the most prevalent epilepsy in adults. Antiepileptic drug (AED) prescription in patients with new-onset focal epilepsy is often challenging. The factors that determine AED of choice depends both on the patient-specific and AED-specific variables. Monotherapy should the initial strategy. Failure to monotherapy can be due to lack of efficacy, severe adverse events, or a hypersensitivity reaction. In such patients, the next strategy should be alternate monotherapy trials. In patients who fail up to three monotherapy trials, duotherapy with drugs having different primary mechanisms of action should be the next step. Multiple duotherapy should be tried before considering adding polytherapy. In spite of such pragmatic strategies, about 25% of patients may never become seizure free for any complete year throughout follow-up. Patients in this group should be evaluated for non-pharmacological treatment options, particularly epilepsy surgery.