Treatment of Gliotic Seizures in Adults
For adult patients with gliotic seizures (structural/remote symptomatic epilepsy), levetiracetam or lamotrigine should be the first-line treatment choice, with oxcarbazepine as an alternative, avoiding enzyme-inducing agents like phenytoin and carbamazepine due to their significant drug interactions and adverse effect profiles. 1
Understanding Gliotic Seizures
Gliotic seizures represent focal epilepsy arising from structural brain lesions (remote symptomatic seizures). These patients face higher recurrence risk compared to idiopathic epilepsy—26% versus 10% at 1 year—making treatment initiation more critical. 2
First-Line Treatment Selection
Preferred Agents
Levetiracetam is an excellent first-line choice for focal epilepsy, offering rapid loading capability (can start at full dosage without titration), minimal drug interactions, and favorable tolerability profile. 3, 1
Lamotrigine represents another first-line option for focal epilepsy with excellent long-term tolerability, though it requires slow titration (6.5 mg/kg single oral load only if previously on lamotrigine for >6 months). 2, 1
Oxcarbazepine is also recommended as first-line therapy for focal epilepsy with established efficacy and favorable side effect profile. 1
Critical Agents to Avoid
Phenytoin and carbamazepine should be avoided as first-line agents despite historical use, because they are cytochrome P450 enzyme inducers that cause hyperlipidemia, accelerate metabolism of concomitant medications, and facilitate osteopenia/osteoporosis development. 1
These enzyme-inducing agents are particularly problematic in patients with comorbid coronary or cerebrovascular disease. 1
Treatment Initiation Strategy
Starting Dosage Approach
Most antiepileptic drugs should be started at low dosage and gradually titrated upward in routine neurological practice to minimize adverse effects while achieving seizure control. 3
Levetiracetam, phenytoin, phenobarbital, and gabapentin are the best tolerated agents for starting at full dosage when rapid onset of therapeutic action is required. 3
The initial target maintenance dosage should be the lowest effective daily dose expected to provide seizure control, adjusted based on individual patient characteristics including stage and severity of epilepsy. 3
Dosage Optimization
If seizures persist on the initial target dose, gradually increase dosage until complete seizure control is achieved or intolerable adverse effects occur. 3
Therapeutic drug monitoring is useful when drug interactions are expected, toxicity is suspected, or when using drugs with nonlinear pharmacokinetics like phenytoin or carbamazepine. 3
No indications currently exist for routine therapeutic drug monitoring of newer antiepileptic drugs like levetiracetam. 3
When Initial Monotherapy Fails
Sequential Monotherapy
In most patients who fail to respond to the initially prescribed drug, switching to another antiepileptic drug (monotherapy) is the best option rather than immediately adding a second agent. 3
Before switching medications, verify the diagnosis of epilepsy and assess adherence to therapy, as these are common reasons for apparent treatment failure. 4
Explore the maximum tolerated dose of each drug before declaring treatment failure, though balance must be struck between adverse effects and seizure control. 4
Combination Therapy Considerations
Combination therapy may be appropriate for patients unresponsive to 2 or more sequential monotherapies, though most patients achieve control on a single agent. 3, 4
When combining agents, carefully select drugs to minimize pharmacokinetic and pharmacodynamic interactions, as poor adherence, drug interactions, and toxicity are more likely with polypharmacy. 4
Never use polytherapy when monotherapy can achieve seizure control to minimize adverse effects and drug interactions. 5
Special Considerations for Structural Epilepsy
Risk Stratification
Patients with remote symptomatic seizures (gliotic lesions) have significantly higher recurrence rates than idiopathic epilepsy—26% versus 10% at 1 year—justifying more aggressive treatment initiation. 2
Abnormal EEG predicts increased recurrence risk in structural epilepsy, supporting early treatment decisions. 2
Treatment Goals
The goal should be complete seizure freedom with a single drug taken once or twice daily without adverse effects, as seizure freedom is achieved in approximately 60-70% of all patients. 1, 4
Up to 70% of people developing epilepsy may expect to become seizure free with optimum antiepileptic drug therapy, with the remaining 30% representing the most difficult to treat. 4
Common Pitfalls to Avoid
Do not use prophylactic anticonvulsants in patients with no seizure history, as they do not reduce first seizure risk. 5
Avoid unnecessary polypharmacy—many epileptic patients could be satisfactorily treated with one drug instead of the polypharmacy they usually receive. 6
Do not prescribe antiepileptic drugs routinely after a first unprovoked seizure unless specific high-risk features are present (sleep-related seizure, epileptiform EEG, structural lesion). 5, 1
Avoid valproic acid in women of childbearing potential due to teratogenic risk and significantly increased risks of fetal malformations and neurodevelopmental delay. 5, 1
Monitoring and Follow-Up
Dosage regimens should be assessed regularly and adjusted if necessary so patients can derive optimal therapeutic benefit. 3
For patients considered 'difficult to treat' (seizures remain incompletely controlled after several treatment attempts), referral to a specialist is recommended. 3
Precise classification of seizure type and epilepsy syndrome, together with careful recording of both seizures and adverse effects, are essential for rational management decisions. 4