When Monotherapy Fails...

Epileptic Disorders Podcast: Weekly DigestFriday, October 23, 2026

Summary

Dr. Jasmine Parihar, a neurologist at the All India Institute of Medical Sciences in New Delhi, addresses a common challenge in epilepsy treatment: what to do when the first anti-seizure medication fails. She emphasizes the importance of thoroughly evaluating the situation before concluding that a medication has failed. Often, the issue may not be drug resistance but rather misdiagnosis, inappropriate drug selection, inadequate dosing, or patient adherence issues.

The discussion outlines a framework for assessing treatment failure, highlighting that incorrect diagnoses, such as seizure mimics, can lead to unnecessary medication changes. Additionally, the choice of medication must align with the specific seizure type and syndrome. Dr. Parihar notes that adherence to medication and lifestyle factors are frequently overlooked causes of apparent treatment failure, with studies indicating that a significant percentage of patients may not be drug-resistant at all.

Once it is determined that a medication has genuinely failed, clinicians have two main strategies: switching to a different monotherapy or adding a second medication. Evidence suggests that both approaches yield similar outcomes, and the decision often depends on individual patient circumstances rather than a clear superiority of one method over the other. The conversation shifts significantly once a patient is classified as having drug-resistant epilepsy, with early consideration of epilepsy surgery becoming crucial to improve the chances of seizure freedom.

Dr. Parihar concludes by stressing the importance of a systematic approach to managing ongoing seizures, advocating for careful evaluation of all potential factors before labeling a medication as ineffective. The discussion sets the stage for future topics, including considerations for anti-seizure medication withdrawal in patients who have achieved seizure freedom.