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The Long-Term Therapeutic Management of Epilepsy

Jacqueline French, MD
[+] Article, Author, and Disclosure Information

From the Graduate Hospital Comprehensive Epilepsy Center and the University of Pennsylvania, Philadelphia, Pennsylvania. Requests for Reprints: Jacqueline French, MD, Department of Neurology, Graduate Hospital Comprehensive Epilepsy Center, One Graduate Plaza, 1800 Lombard Street, Philadelphia, PA 19146. Acknowledgments: The author thanks Henry Fraimow, MD; Oliver French, MD; Marc A. Dichter, MD, PhD; Philip MacDonald, PhD; and Jackie Gordon, PhD, for their review of the manuscript.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1994;120(5):411-422. doi:10.7326/0003-4819-120-5-199403010-00010
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Objective: To provide a rational strategy for the evaluation and long-term management of epilepsy.

Data Sources: Articles written between 1964 and 1993, obtained from a MEDLINE search on epilepsy-related topics as well as from the author's personal files, major reference books on antiepileptic drugs, and references identified from these books.

Study Selection: Articles were selected if they contained well-documented information comparing antiepileptic drugs, represented controlled clinical trials, or were considered “key” articles of clinical relevance.

Data Synthesis: Epilepsy is a chronic condition requiring careful long-term management. The treatment is complex, involving classification and diagnosis, selection and monitoring of the appropriate antiepileptic agent, and evaluation of the chosen drug's side effects and drug interactions. Because these side effects increase when drugs are combined, monotherapy is recommended. Long-term management issues and optimal drug selection differ from patient to patient. If seizures are not controlled by medication, the patient may have been misdiagnosed or misclassified. Noncompliance, a major cause of apparent unresponsiveness to treatment, should also be ruled out. Recognizing that current therapy is not ideal for many patients, new pharmacologic and surgical therapies are briefly discussed.

Conclusions: Physicians can pursue a rational strategy for the management of epilepsy if they understand the risks and benefits of various pharmacologic and therapeutic options and if they maintain open lines of communication with the patient.


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Figure 1.
Long-term management paradigm for patients with epilepsy.

Celontin = methsuximide; EEG = electroencephalogram; Mesantoin = mephenytoin; MEMS = Medication Event Monitoring System; Phenurone = phenacemide; and Rx = drug treatment.

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