CNS Drugs

, Volume 19, Issue 11, pp 897–908 | Cite as

Overtreatment in Epilepsy

How It Occurs and How It Can Be Avoided
Current Opinion

Abstract

In pharmacotherapy, overtreatment may be defined as an excessive drug load (that is, excessive drug dosages or unnecessary polypharmacy) leading to a suboptimal risk-to-benefit ratio. The risk of overtreatment in the pharmacological management of epilepsy is substantial and may have serious consequences in terms of a greater incidence and severity of adverse effects. These effects can range from subtle CNS impairment to overt toxic effects, including teratogenicity. Overtreatment also causes increased treatment costs and may even lead to a paradoxical deterioration in seizure control. The prevention and correction of overtreatment requires a thorough understanding of the situations and mechanisms that lead to inappropriate prescribing of antiepileptic drugs. These include initiating treatment in conditions where it is not indicated (for example, long-term prophylaxis after head trauma or supratentorial surgery in seizure-free patients), use of excessively fast titration rates, prescription of excessively high initial target dosages, failure to consider conditions associated with reduced dosage requirements (for example, old age or comorbidities associated with impaired drug clearance), and failure to consider the dose-response characteristics of the selected drug. Many patients whose seizures do not respond to the initially prescribed medication can be optimally managed by switching to monotherapy with an alternative agent; premature use of combination therapy represents another common form of overtreatment. Overtreatment may also result from a failure to adjust the dosage to prevent or compensate for adverse pharmacokinetic or pharmacodynamic drug interactions, and from a failure to reduce drug load in patients who have not benefited from high dosages or polypharmacy. While the measurement of drug concentrations can aid in minimising adverse effects, there is also a danger of overtreatment resulting from inappropriate interpretation of drug concentration data. Continuation of drug therapy in seizure-free patients in whom the risk-benefit ratio is in favour of gradual withdrawal may also be regarded as overtreatment.

Tailoring therapy to the needs of the individual patient is the key to the successful management of epilepsy. Even though the importance of complete seizure control cannot be overemphasised, no patient should be made to suffer more from the adverse effects of treatment than from the manifestations of the seizure disorder.

Keywords

Lamotrigine Seizure Control Serum Drug Concentration Juvenile Myoclonic Epilepsy Childhood Absence Epilepsy 

Notes

Acknowledgements

Dr Perucca has received speaker’s or consultancy fees and/or research grants from Novartis, Pfizer, UCB Pharma, Sanofi Aventis, GlaxoSmithKline, Johnson and Johnson and Eisai. Dr Kwan has received speaker’s or consultancy fees and/or research grants from Pfizer, UCB Pharma and Johnson and Johnson. No sources of funding were used to assist in the preparation of this review.

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© Adis Data Information BV 2005

Authors and Affiliations

  1. 1.C. Mondino FoundationInstitute of Neurology IRCCSPaviaItaly
  2. 2.Department of Internal Medicine and TherapeuticsUniversity of PaviaPaviaItaly
  3. 3.Division of Neurology, Department of Medicine and TherapeuticsThe Chinese University of Hong Kong, Prince of Wales HospitalShatinHong Kong

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