Abstract
Antiepileptic drug (AED) monotherapy is the preferred initial management approach in epilepsy care, since most patients may be successfully managed with the first or second monotherapy utilized. This article reviews the rationale and evidence supporting preferential use of monotherapy when possible and guidelines for initiating and successfully employing AED monotherapy. Suggested approaches to consider when patients fail monotherapy include substituting a new AED monotherapy, initiating chronic maintenance AED polytherapy, or pursuit of non-pharmacologic treatments such as epilepsy surgery or vagus nerve stimulation. Reducing AED polytherapy to monotherapy frequently reduces the burden of adverse effects and may also improve seizure control. AED monotherapy remains the optimal approach for managing most patients with epilepsy.
Highlights
Epileptic seizures have been observed since antiquity [57]
Antiepileptic drug (AED) monotherapy may fail for a variety of reasons, including errant diagnosis, inaccurate diagnosis of seizure type leading to ineffective AED choice, intolerable adverse effects, idiosyncratic reactions, noncompliance, over treatment, [50] and pharmacogenetic factors [53]
Monotherapy is preferred when managing patients with epilepsy, given similar efficacy and superior tolerability compared to polytherapy for most patients, especially those with newly diagnosed epilepsy who are not refractory to other treatments
Summary
Epileptic seizures have been observed since antiquity [57]. Treatment preferences generally favored polytherapy prior to the evolution of modern antiepileptic drugs (AEDs). Four second-generation AEDs are FDA approved for use as monotherapy, with some limitations; these are oxcarbazepine, lamotrigine, topiramate, and felbamate [17].
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