When the antiepileptic drugs are not working.

Most patients with epilepsy respond to the initial antiepileptic drug (AED). But, as the responders are discharged, our clinics inevitably accumulate a number of "refractory" patients who require more manipulation of their treatment. This article looks at ways in which the identification and management of refractory epilepsy can be enhanced. The most important thing is to be able to assess if the initial diagnosis and classification are correct, and if the epilepsy is genuinely refractory, or if other medical or social issues are contributing to the deterioration in AED control. Once any treatment resistance is confirmed, specific attention should be paid to thorough investigation and, if appropriate, treatment manipulation. As all AEDs are equally efficacious, it is knowledge of the drug pharmacology and of expected adverse effects that is most helpful in determining drug choice. For those patients who do not fully respond to any medication, the challenges are to provide maximum benefit with minimum adverse effects, reducing risk to life, and risk to quality of life.