Standard approach to antiepileptic drug treatment in the United Kingdom.

In the United Kingdom, the question of whether to commence antiepileptic drug (AED) treatment remains controversial. Surveys indicate that 15% of patients are treated after a first seizure. Pediatricians often wait for a third or fourth seizure before treating, whereas clinicians who deal with adult patients are more likely to intervene early, largely because of concerns about driving and employment. Monotherapy is becoming the rule for the majority of patients. The four primary AEDs in the United Kingdom are carbamazepine and phenytoin (approximately 30% each), valproate (VPA; approximately 25%), and phenobarbital (approximately 18%). For partial epilepsies, studies show few major differences in efficacy among these four AEDs. A firstline AED should be one, such as VPA, with a broad spectrum of activity that is easily managed by clinicians who may not have special expertise in the recognition of differing seizure types and epilepsy syndromes. Where differences in efficacy are marginal, comparative drug toxicity may be a major factor in AED selection. Most new AEDs have low toxicity profiles. With respect to discontinuation, pediatricians usually recommend a trial discontinuation period in most children who achieve a 1- or 2-year remission of epilepsy. For adults, however, overall relapse rates after discontinuation are approximately 40-50%; therefore, patients usually opt for long-term AED therapy.