Treating patients with medically resistant epilepsy

Recent evidence suggests that medically resistant epilepsy can be identified if seizures persist de-spite adequate doses of 2 appropriate first-line an-tiepileptic drugs (AEDs). Patients with medically resistant epilepsy should have their seizures care-fully characterized in order to confirm their diagno-sis, select treatment, and assist in determining prognosis. Patients should be counseled about fac-tors that aggravate epilepsy and the importance of adhering to treatments. Physicians should care-fully inquire about side effects and alter therapy to eliminate or minimize these symptoms. Uncon-trolled seizures cause injuries, disability, and in-creased mortality, so surgery should be considered as soon as seizures are proven to be medically re-sistant. Patients with incomplete response to AEDs and who are not surgical candidates may benefit from additional medication trials or from palliative nonmedical therapies, such as vagal nerve stimulation. W hat is medically resistant epilepsy? Medically resistant epilepsy would seem to be a self-evident term, refer-ring to patients whose seizures persist despite using antiepileptic drugs (AEDs). The defini-tion, however, relies as much upon pharmacologic efficacy and physician treatment skills as the underlying biology and natural history of epilepsy. One might have hoped that the devel-opment of nearly a dozen new drugs for epilepsy in the 1990s and 2000s would have simpli-fied this definition. Unfortunately, while many newer drugs have superior pharmacokinetic and side-effect profiles than older AEDs, they possess the same degree of effectiveness. These AEDs rarely stop seizures once older agents have failed. Hence, until innovative pharmaceuti-cal approaches yield better response rates, we must conclude that medical resistance is biolog-ically determined and innate in some forms of epilepsy