What are the treatment implications of the study of Kwan and Brodie?
The first is that knowing that initial therapy has failed for a patient is not sufficient to label the epilepsy as treatment refractory; the cause of failure must be known. Patients for whom treatment failed for reasons other than lack of efficacy ultimately did as well as early drug responders. It also is important to keep in mind that the study used only complete seizure freedom as an outcome. Some patients may have been experiencing only rare breakthrough seizures. Moreover, it is quite likely that many patients for whom the first drug fails may experience a seizure reduction with alternate therapy. However, for most patients, complete seizure freedom is the goal. These findings certainly support early referral for surgical evaluation. They also may support the use of one of the newest AEDs as a second therapeutic trial, although more data are needed to direct second therapy.
