Drug treatment of epilepsy. Outlines, criticism and perspectives

This article focuses on important aspects relevant to the assessment of antiepileptic treatment and critically reviews the existing knowledge in this area. The principal variables considered are the commencement of treatment, choice of appropriate drug, efficacy of monotherapy, and cessation of treatment. When seizure recurrences after the first unprovoked seizure are considered, contradictory data have been provided on the role of early (i.e. after the first seizure) therapy in preventing relapses. The choice of the appropriate drug seems to be dictated more by clinical toxicity than by truly greater efficacy since there is no evidence of significant differences in efficacy among the 'major' anticonvulsants such as phenytoin, phenobarbitone, carbamazepine and primidone. Monotherapy is the preferred treatment, at least in previously untreated patients, since up to 90% of cases are completely controlled after variable periods of observation. Cessation of therapy after prolonged seizure control is followed by relapses in a varying percentage of cases depending on several factors, among which is the duration of the period of control. As yet, a definitive comparison of the available information has been prevented by major methodological differences and by partial investigation of the various aspects of the care of the patient with epilepsy. To provide a tentative answer to some of the open questions concerning the impact of anticonvulsant therapy on the prognosis of the disease, an alternative approach has been proposed, based on the active surveillance of a cohort of newly referred patients started on monotherapy in routine care conditions over a period of more than 5 years. The feasibility of this approach is being tested in a multicentre prospective study currently in progress in Italy.