More Open Discussion of Epilepsy Treatment Options Is Needed

Clinicians must be more prepared to discuss the full range of options for refractory epilepsy treatment with their patients, according to a critical review published in Epilepsy & Behavior.

Within the review, a team of 8 epilepsy researchers from Europe, the United States, and South America pointed out that refractory epilepsy patients generally have greater economic and psychosocial burdens, as uncontrolled seizures could be associated with structural damage to the brain and nervous system; comorbidities like osteoporosis; increased mortality from suicide, accidents, sudden unexpected death in epilepsy (SUDEP), pneumonia, or vascular disease; and psychological issues like depression and anxiety. Therefore, the scientists called for further research focused on preventing such consequences and attempting to control epileptic seizures.

Epilepsy progression is generally defined as not only the worsening of seizure control over time, but also declines in cognition, behavior, structural abnormalities, electroencephalography (EEG) patterns, or social interactions among those without underlying progressive brain disorders. However, the review authors circled back to the long-standing concept that seizures beget seizures, which has remained popular among epilepsy theorizers.

The investigators determined that aiming toward the goal of “no seizures, no adverse effects” is a necessary yet insufficient method to improve quality of life (QOL) in refractory epilepsy patients. As a result, “concepts of aggressive treatment must take a broader scope by incorporating early diagnosis and treatment of comorbidities,” the authors advised.

The researchers also analyzed the risks associated with antiepileptic drugs (AEDs), which they divided into various categories: dosage-related; hypersensitivity reactions; long-term adverse events; adverse drug-on-drug reactions; long-term, adverse hormonal and metabolic effects; and structural and cognitive teratogenicity. The reviewers noted that all AEDs have the potential for adverse effects, which are not mutually exclusive.

Other treatment options explored included resective surgery, corpus callosotomies, and hemispherectomies, which are generally considered to be riskier treatment options. For those who desire to be seizure-free, the researchers determined that vagus nerve stimulation, deep-brain stimulation, and responsive neurostimulation are the best minimally invasive neurostimulation options with the fewest negative side effects. While dieting is also an option, it is not typically well tolerated among patients over time.

“The risk of doing nothing or avoiding an efficacious treatment associated with an increased risk must be included in the risk-benefit discussion,” the authors wrote. “Clearly, for some patients, the risk of a potentially high-risk treatment is significantly less than the risk of a potential adverse effect from ongoing seizures. Clinicians need to include assessments of loss of life, quality of life, and epilepsy morbidities as part of any treatment discussion.”