Monthly Case

A 33-year-old female patient with intellectual disability suffers from epilepsy with complex-partial and former secondary generalized seizures since early childhood. Etiology is unclear, brain MRI demonstrates at most some moderate global cortical atrophy. The patient has a history of taking 10 different antiepileptic drugs, currently she is administered 3,000 mg levetiracetam, 1,800 mg carbamazepine, and 400 mg lacosamide. Despite this triple-therapy, the patient still suffers from 2-3 complex-partial seizures per month. Furthermore, the patient has a most likely cerebellar gait disorder, she complains about unspecific dizziness.

We had the assumption that her complaints are explained by the antiepileptic medication and withdrew carbamazepine step by step. The dose of the two other antiepileptic drugs remained unchanged. Six months later, the patient was admitted for re-assessment. The objective and subjective complaints had ceased, seizure frequeny remained unchanged.

This case nicely illustrates the findings of a long-term study on 148 patients with antiepileptic polytherapy (Poolos et al. 2012 Neurology). This study demonstrates that three antiepiletic drugs administered at the same time are not more efficacious than two substances, but that adverse events are seen more frequently and with more severity. This in particular accounts for co-administration of two or more antiepiletic drugs with concordant mechanisms of action, in this case the sodium channel blockers carbamazepine and lacosamide.

In summary, even patients with difficult-to-treat epilepsy ideally should not be administered more than two antiepileptic drugs simultaneously. In general, withdrawal of further antiepileptic drugs is worthwhile.

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