The decision whether or not to initiate drug therapy after a single seizure remains controversial since approximately 25% of patients may not have another seizure. Some advocate treatment on the basis that early initiation may improve prognosis but the matter has not yet been resolved.
1. Therapy should start with a single well-tried and safe drug. The majority of patients (70%) can be controlled on one drug (monotherapy).
2 Greek katamenios, monthly appropriate to the type of seizure disorder. Although some drugs have a wide spectrum of action against different seizure types, some are more specific and may even aggravate certain seizure types. Carbamazepine is a drug of first choice for focal and secondary generalised epilepsy but aggravates myoclonic and absence seizures. Sodium valproate and lamotrigine have a wide spectrum of action and are active against both primary and secondary generalised epilepsy.
3. Choice of drug is also determined by the patient's age and sex. This is particularly true for women who prefer to avoid drugs associated with teratogenesis or that have adverse effects on their appearance, e.g. hirsutism from phenytoin.
4. If the attempt to control a patient's epilepsy by use of a single drug is unsuccessful, it should be withdrawn and replaced by a second line drug, though these are effective in only about 10% of patients. There is little evidence that three drugs are better than two, and not much that two are better than one. More drugs often mean more adverse effects.
5. Abrupt withdrawal. Effective therapy must never be stopped suddenly either by the doctor (carelessness) or by the patient (carelessness, intercurrent illness or ignorance), or status epilepticus may occur. But if rapid withdrawal is required by the occurrence of toxicity, a substantial dose of another antiepilepsy drug should be given at once.
6. In cases where fits are liable to occur at a particular time, e.g. the menstrual period, dosage should be adjusted to achieve maximal drug effect at that time or drug treatment can be confined to this time. For example, in catamenial epilepsy, clobazam can be useful given only at period time.
Generally drugs are best given as a single or twice daily dose to increase compliance. Many patients dislike taking medication to work or school and being seen to take it but, necessarily, drugs with short duration of action may require to be taken three or even four times a day.
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