title: The consequences of refractory epilepsy and its treatment.
abstract: Seizures in some 30% to 40% of patients with epilepsy fail to respond to antiepileptic drugs or other treatments. While much has been made of the risks of new drug therapies, not enough attention has been given to the risks of uncontrolled and progressive epilepsy. This critical review summarizes known risks associated with refractory epilepsy, provides practical clinical recommendations, and indicates areas for future research. Eight international epilepsy experts from Europe, the United States, and South America met on May 4, 2013, to present, review, and discuss relevant concepts, data, and literature on the consequences of refractory epilepsy. While patients with refractory epilepsy represent the minority of the population with epilepsy, they require the overwhelming majority of time, effort, and focus from treating physicians. They also represent the greatest economic and psychosocial burdens. Diagnostic procedures and medical/surgical treatments are not without risks. Overlooked, however, is that these risks are usually smaller than the risks of long-term, uncontrolled seizures. Refractory epilepsy may be progressive, carrying risks of structural damage to the brain and nervous system, comorbidities (osteoporosis, fractures), and increased mortality (from suicide, accidents, sudden unexpected death in epilepsy, pneumonia, vascular disease), as well as psychological (depression, anxiety), educational, social (stigma, driving), and vocational consequences. Adding to this burden is neuropsychiatric impairment caused by underlying epileptogenic processes ("essential comorbidities"), which appears to be independent of the effects of ongoing seizures themselves. Tolerating persistent seizures or chronic medicinal adverse effects has risks and consequences that often outweigh risks of seemingly "more aggressive" treatments. Future research should focus not only on controlling seizures but also on preventing these consequences.
authors: Sutter Pacific Epilepsy Program, California Pacific Medical Center, San Francisco, CA, USA. Electronic address: laxerkd@sutterhealth.org.
authors: Kenneth D
authors: KD
authors: Laxer
authors: Department of Neurology, Christian Doppler Medical Centre, Paracelsus Medical University, Salzburg, Austria; Centre for Cognitive Neuroscience, Salzburg, Austria.
authors: Eugen
authors: E
authors: Trinka
authors: Division of Epilepsy and EEG, Department of Neurology, Yale Comprehensive Epilepsy Center, New Haven, CT, USA.
authors: Lawrence J
authors: LJ
authors: Hirsch
authors: Department of Neurology, University of Campinas (UNICAMP), Campinas, Brazil.
authors: Fernando
authors: F
authors: Cendes
authors: Department of Neurology, University of Rochester School of Medicine, Rochester, NY, USA; Department Psychiatry, University of Rochester School of Medicine, Rochester, NY, USA; Strong Epilepsy Center, University of Rochester School of Medicine, Rochester, NY, USA.
authors: John
authors: J
authors: Langfitt
authors: Epilepsy Service and National Epilepsy Surgery Programme, Beaumont Hospital, Dublin, Ireland.
authors: Norman
authors: N
authors: Delanty
authors: Comprehensive Epilepsy Program, Miami Children's Hospital, Miami, FL, USA.
authors: Trevor
authors: T
authors: Resnick
authors: Comprehensive Epilepsy Program, University of South Florida, Tampa, FL, USA.
authors: Selim R
authors: SR
authors: Benbadis
mesh_terms: D000927:Anticonvulsants / Q000009:adverse effects / Q000627:therapeutic use; D004351:Drug Resistance; D004827:Epilepsy / Q000150:complications* / Q000188:drug therapy / Q000401:mortality / Q000628:therapy*; D006801:Humans
chemical_list: D000927:Anticonvulsants
keywords: Antiepileptic treatment; Comorbidities; Epilepsy; Mortality; Safety; Sudden unexpected death in epilepsy