Ideal situation: Carbamazepine is generally the drug of choice for symptomatic focal epilepsies in the industrialized world, and the extended release form is preferred because twice-a-day dosing is possible. Although phenytoin is as effective and can be given once a day, it is less often prescribed because of the cosmetic side effects and saturation kinetics. Oxcarbazepine is similar to carbamazepine and is being increasingly used as a first-line drug. Other drugs that are commonly tried if the first-choice drug fails, in no particular order, include valproate, lamotrigine, topiramate, levetiracetam, and zonisamide. Because efficacies are similar, decisions are based more on side effect profiles and dosage regimens acceptable to each individual patient. Tiagabine is less commonly used, and drugs that are sedating, such as phenobarbital, primidone, and the benzodiazepines, are usually avoided. Felbamate and vigabatrin are extremely effective antiepileptic drugs with serious toxicity, so they are generally considered a last resort, to be used with full patient disclosure. Not all of these drugs are available in every country, and regulations vary with respect to use as monotherapy, or as adjunctive medications for some of the newer drugs.
Contingency situation: Very often, ideal treatment schedules cannot be practiced in developing countries due to the poor availability of drugs and the costs involved. Therefore, flexibility on the part of the treating physician is important for planning con tingency alternatives. In developing countries with limited resources, an alternative contingency strategy (though not ideal) could be to begin with phenobarbital, and if that fails, go on to use phenytoin, carba-mazepine, or valproate. While commonly used AEDs (PHT, PB, CBZ, and VPA) have been shown to have differential efficacy in comparative studies, there is no conclusive evidence that these and other AEDs have differential efficacy against partial seizures arising from different parts of the brain.
PB is no longer used as a first-line drug by most people in developed countries due to its adverse cognitive and behavioral effects, but may be the drug of choice for developing countries, especially for patients who are struggling for subsistence. There are real-life situations in developing countries where the cost of AEDs becomes the most important adverse effect. Very often the issue at stake is whether to treat epilepsy or provide food and clean water. Clinicians in developing countries could follow the simple strategy to initiate treatment with PB and be ready to change to other AEDs in case of disabling adverse effects with PB.
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