Epilepsy Treatment in the 21st Century

By Shinnar, Shlomo | The Exceptional Parent, October 1999 | Go to article overview

Epilepsy Treatment in the 21st Century


Shinnar, Shlomo, The Exceptional Parent


Over the last 20 years, there have been many advances in the medical treatment of childhood epilepsy. These include: the development of new medications; the increasing utilization of surgery; the availability of better diagnostic tools; a better understanding of the basic mechanisms of seizures and how these are different in children; and a better appreciation of the natural history of the disorder. This article will focus on issues relating to medical therapy of childhood seizures.

Approaching therapy

The basic approach to medical therapy has not changed, though specific choices of medications have. The choice of antiepileptic medications (AEDs) is based on the seizure type, the epilepsy syndrome, and individual factors such as age, gender, other medical conditions, and which potential side effects are more acceptable to the family. Treatment is initiated with a single AED, which is then gradually increased until seizure control is achieved or toxicity (unacceptable levels of side effects) occurs. If one drug is inadequate, a second drug is introduced. There is some controversy in the medical community over whether the second drug should be added or the first drug should be withdrawn. This is really a risk/benefit issue that needs to be approached on an individual basis. If the second AED is effective, then withdrawal of the first drug should be considered. If two or three AEDS have failed to achieve seizure control, then the child should be considered medically refractory and referred for further evaluation and treatment.

The newer AEDS are being used more and more in children, and it is anticipated that, over the next five to ten years, some may become first-line drugs (i.e., the medication used in the initial attempt to control seizures). They are particularly welcome additions in the treatment of the refractory generalized childhood epilepsies such as the Lennox-Gastaut syndrome. Until recently, only valproate was available as a first-line drug for these syndromes, whereas several of the new drugs are proving effective. However, at present there is insufficient experience with them in children to consider them first-line drugs for children. In particular, more information is needed about possible adverse effects, including behavioral and cognitive, associated with the use of these drugs in children. This is a major focus for future research.

Monitoring the child for adverse effects is a joint venture between the family and clinician. Routine laboratory evaluations of asymptomatic children, though frequently performed, are of little value. Evaluations are necessary when the child develops symptoms. Understanding adverse effects means monitoring children as they use an AED. Each person's physical make-up--height, weight, metabolism rate--determines how he or she responds to medication. For some people the "therapeutic"--or average dose rate--level will actually be "toxic." "Therapeutic" levels are merely useful statistical ranges that help guide treatment and indicate whether there are unusual problems with absorption, metabolism, or compliance for the person taking the medication. Some children are fully controlled with "subtherapeutic" doses. Other children require and tolerate "toxic" doses for control of their seizures. Parents need to be aware that, particularly with the newer drugs, the therapeutic range has not been well defined, and there is no precise correlation between serum levels and biological activity.

AED therapy

For many years, the goal of medical care has been the suppression of seizures without producing unacceptable side effects. This has and will remain unchanged. What has changed is our appreciation of both sides of this effort: seizures and side effects.

We have learned that the majority of children with seizures do well and eventually outgrow their seizures. Isolated seizures, even if prolonged, are only rarely associated with any detectable damage. …

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