POLYPHARMACY WITH ANTICONVULSANTS - FOCUS ON SYNERGISM

For almost 20 years, anticonvulsant, monotherapy has been regarded as the ideal method of management of epilepsy. This line of thought, whil e true, has mutated into a general view of polypharmacy with anticonvu lsants as a sign of therapeutic failure, However, even when the 'right ' drug is given at the 'right' dose, studies have shown that in around 30% of patients, epilepsy will not fully respond to anticonvulsant mo notherapy, For these patients, polypharmacy with anticonvulsants is an inevitability, There are good reasons why the established anticonvuls ants should not be particularly well tolerated in combination, However , anticonvulsant polypharmacy has become so 'undesirable' that there h as been a failure to search for firm treatment strategies for refracto ry epilepsy, Nevertheless, there are strong arguments to suggest that the newer anticonvulsants will prove to be better tolerated in combina tion than their established counterparts, particularly in view of thei r paucity of drug interactions, more predictable pharmacokinetics and narrower spectrum of action, This review calls for the development of a rational plan for the treatment of refractory epilepsy, Proper doubl e-blind trials should be carried out to compare the efficacy and toler ability of anticonvulsant drug combinations, This is a huge task that could be rationalised by concentrating on combinations that have been reported to have particular benefit, or those with neurochemical prope rties that suggest an additive or even synergistic effect.