Drug-resistant epilepsy
Failure of two appropriately chosen and adequately tried antiseizure medicine schedules should trigger a change in thinking, not simply an endless sequence of additional prescriptions.
The ILAE core definition
Drug-resistant epilepsy is generally defined as failure of adequate trials of two tolerated, appropriately chosen and used antiseizure medication schedules — alone or in combination — to achieve sustained seizure freedom.
Recheck the diagnosis
Are all ongoing events epileptic? Could syncope, functional seizures or another mimic be contributing?
Recheck classification and localisation
Review seizure semiology, EEG and epilepsy-protocol MRI; classification errors can produce apparent drug resistance.
Consider epilepsy surgery early
For suitable focal epilepsies, resective or ablative surgery may offer a chance of seizure freedom that further medication trials cannot match.
Consider neuromodulation
Vagus nerve stimulation, deep brain stimulation and other neurostimulation approaches can reduce seizure burden in selected patients.
Dietary therapy can be a treatment, not an afterthought
Ketogenic and related dietary therapies have an established role in selected epilepsies, particularly in paediatric and developmental epileptic encephalopathy settings, under experienced multidisciplinary supervision.
Wise escalation
Before adding drug number three, four or five, ask whether the diagnosis, epilepsy type, adherence, provoking factors, pharmacology and non-drug options have been revisited. “More treatment” and “better treatment” are not the same thing.
Return to the four-question frameworkReference: ILAE consensus definition of drug-resistant epilepsy and ILAE surgical-therapy resources.