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McMaster Textbook of Internal Medicine

The future of drug-resistant epilepsy management: new drugs, surgery, DBS

2023-05-17
Wieslaw Oczkowski
Recorded at the 7th McMaster International Review Course in Internal Medicine (MIRCIM).

Wieslaw Oczkowski, MD, is a professor emeritus in the Department of Medicine at McMaster University and director of the Regional Stroke Network for the Central South Ontario Region.

What is more likely to bring a breakthrough in the management of drug-resistant epilepsy: the development of new drugs with novel mechanisms of action or wider use of nonpharmacologic interventions, such as epilepsy surgery or, possibly, deep brain stimulation (DBS)?

I think, again, it goes back to what the epilepsy etiology is. It will respond differently to different medical drug treatments. However, there are new medications that seem to be very promising for the management of epilepsy, especially refractory epilepsy. They have different mechanisms of action. Unfortunately, we often find, the longer they’ve been out on the market and we’ve been using them, that they’re not as fantastic as they originally seemed in the clinical trials because clinical trials tend to have patients who are selected in some ways and in the general practice the medications behave differently.

The future will be different. The future will involve more epilepsy surgery. A surgery for epilepsy, focal lesional epilepsy, is extremely effective, much more so than multiple medications. So that will be a focus in the future.

The brain itself is an electrical device and in the future the management of epilepsy may be more [about] managing the electrical device as opposed to the [use of] neurochemicals itself. I think that will be the forefront.

See also
  • The role of seizure semiology and etiology for treatment decision-making When using antiseizure treatment, why do we continue to rely on seizure morphology rather than use biologic, metabolic, or genetic markers in an attempt to individualize therapy (possibly with the exception of vigabatrin in infantile spasms associated with tuberous sclerosis)?
  • Chronic seizure management in patients with drug-resistant epilepsy We have a broad and still growing selection of antiseizure medications available, and yet drug resistance remains a challenge in roughly a third of patients with epilepsy. Why is this rate so high and how can we improve chronic seizure management in these patients?
  • Brain tumors: High-yield information Dr Navya Kalidindi from McMaster University provides a state-of-the-art update on the diagnosis and management of brain tumors.
  • Major areas to improve perioperative care and outcomes Dr Flavia Kessler Borges, Dr Sandra Ofori, and Dr Michael McGillion reflect on the key messages from the HIP ATTACK-2, PREVENT, and PVC-RAM 2 and 3 trials.
  • Cannabinoids in patients with epilepsy What is the current place of cannabidiol and other cannabinoids in the treatment of epilepsy? How often are OTC cannabinoid preparations used by patients with epilepsy in North America? How does it affect the clinical management of epilepsy?
  • Novel antiseizure drugs as first-line treatment Novel antiseizure drugs are typically approved as adjunctive therapy, to be used as an add-on. It might take years until their registration is expanded to include initial monotherapy. Do you think that cenobamate and other novel drugs could reduce the rates of drug resistance when introduced earlier, even as first-line medications in selected patients?

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