THE TREATMENT OF EPILEPSY: WHEN SHOULD ANOTHER ANTI-EPILEPTIC DRUG BE GIVEN?
As mentioned above, the first choice drug should be used alone (monotherapy) and in the lowest dose to control seizures without producing any unacceptable side-effects. If the initial control of seizures is less than complete, then the dose of that drug should be increased gradually until either complete control is achieved, or side-effects develop. If unacceptable side-effects occur before control is reached, then there are two alternatives: either a different drug can be used to replace the first drug, or an additional drug can be added to the first drug. Which alternative is chosen depends on the individual patient and also on the doctor. If there has been some reasonable control with the first drug, it is our practice to add the next most appropriate
anti-epileptic drug without withdrawing the first drug. If complete seizure control is then achieved, we will attempt to withdraw the first drug after a period of two to three months free from seizures. If the initial drug has been ineffective we would simultaneously replace the first drug with the second. In some children and adults, therapy with two anti-epileptic drugs is justified, as this may result in further significant (even complete) control in an additional 5 per cent to 10 per cent of children. It is unlikely that polytherapy with three drugs will result in any further control, and there is certainly an increased risk and frequency of side-effects and toxicity due to interactions between this many drugs.
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