The aim of epilepsy treatment is cessation of seizures without side effects. In the course of treating the child, the family should be informed, based on their level of medical sophistication, about choices of treatment and options for dealing with the condition and its consequences. Both seizures and therapies carry risks and optimal patient care requires thoughtful balancing of these risks and benefits. To provide the best care, the physician must be aware of the available options and individualize them to the needs of the specific child (see Chapter 2).
The goals of treatment will differ considerably depending upon the severity of the epilepsy syndrome. Many childhood epilepsies are easily controlled with modest doses of medication (i.e., childhood absence epilepsy, benign epilepsy with centrotemporal spikes, and idiopathic generalized epilepsies). For these children, selecting a treatment that has no major adverse effects, yet produces seizure control in a convenient manner is a reasonable goal. Contrasted to this are children with severe forms of epilepsy, often with multiple seizure types and pharmacoresistant seizures (i.e., infantile spasms, Lennox–Gastaut syndrome and symptomatic partial onset epilepsies). For these disorders, selecting a treatment with an elevated risk–benefit ratio may be acceptable to gain improvement in seizure control. Additionally, in this group considerations of all therapeutic options should be undertaken. Finally, realistic goals for seizure control should be balanced with chronic medication side effects (especially sedation). The management of epilepsy should be conceived as a global therapeutic strategy applied to an individual child. This chapter will provide general recommendations for antiepileptic drug (AED) follow-up and withdrawal, which the physician must individualize for each child by forming a therapeutic alliance with the family.
ENSURING THAT A CHOSEN DRUG IS EFFECTIVE
Treatment should always be initiated with a single antiepileptic drug and the dose slowly increased until the seizures are controlled or until clinical toxicity occurs. Antiepileptic drugs should never be stopped abruptly unless a serious adverse event occurs (i.e., rash).
Only one in five children with epilepsy will have "smooth sailing epilepsy" (i.e., they start on an antiepileptic drug, become instantly seizure-free, and eventually come off medication and remain in remission). However, an additional 40% of children will become seizure-free with the first antiepileptic drug, after some dose adjustment to deal with subsequent seizures.1 In general, the first antiepileptic drug will eventually be successful in controlling the seizures in 50%–70% of children. Antiepileptic drug therapy should be assessed in light of the epilepsy syndrome and a risk-to-benefit profile established when considering the various antiepileptic drugs. Initiation of antiepileptic therapy should be done with a realization that about half of the time the initial antiepileptic drug will be changed. As a result, compatibility of the initial antiepileptic drug with future antiepileptic drugs should be considered when initial therapy is begun. If monotherapy fails, and a combination of antiepileptic drugs is ...