Avoiding complacency when treating uncontrolled seizures: why and how?

ABSTRACT

Introduction: Despite the advances in the diagnosis and treatment of epilepsy, approximately 30% of the patients remain intractable. Uncontrolled seizures have deleterious consequences, including brain damage, cognitive decline, decreased quality of life, and increased mortality.

Areas covered: In this article, the authors discuss the treatment gap in patients with intractable epilepsy and the possible mechanisms of drug resistance. The authors provide a treatment algorithm for patients with intractable epilepsy, including non-pharmacological treatment options, such as diet, neurostimulation (vagus nerve stimulation, responsive neurostimulation, and deep brain stimulation), curative surgeries, and palliative surgeries.

Expert opinion: There are currently several gaps in the management of seizures. Thirty percent of the 1% of the population with epilepsy is drug resistant. Non-pharmacologic treatments have improved in the last 30 years and continue to do so, but epilepsy surgery in general is still vastly under-utilized. Resective surgery is the only potentially curative procedure. Neurostimulation is generally palliative and is also improving, with smarter types of neurostimulation and paradigms.

KEYWORDS:

• Seizure freedom
• intractable epilepsy
• quality of life
• epilepsy surgery
• epilepsy treatment algorithm

Article highlights

• Despite advances in pharmacotherapy, about 30% of the patients with epilepsy are drug-resistant.

• There is a significant delay in referring this group of patients to tertiary epilepsy centers, and thus there is a long treatment gap.

• The consequences of uncontrolled seizures are serious and include brain damage, cognitive decline, neuropsychiatric comorbidities, reduced quality of life, and increased mortality.

• In this article, the authors discuss hypotheses for the mechanisms of drug resistance.

• The authors provide treatment guidelines on how to choose appropriate anti-epileptic drugs, and an algorithm on how to approach patient with drug-resistant epilepsy.

Declaration of interest

S Benbadis has acted as a consultant for Bioserenity (DigiTrace), Brain Sentinel, Cavion, Ceribell, Eisai, Greenwich, Growhealthy, LivaNova, Neuropace, SK Biopharmaceuticals and Sunovion. S Benbadis has also received speakers bureau from Eisai, Greenwich, LivaNova, Sunovion as well as Grant support from Cavion, LivaNova, Greenwich, SK Biopharmaceuticals, Sunovion and Takeda. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or conflict with the subject matter or materials discussed in this manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This work was funded by SK Life Sciences. The authors thank Debika Chatterjea, PhD, of MedVal Scientific Information Services, LLC (Princeton, NJ, USA) for medical writing and editorial assistance, which were funded by SK Life Sciences.