Monotherapy in adults and elderly persons.

Treatment of epilepsy with a single drug has many advantages. Potential benefits of monotherapy vs polytherapy include fewer adverse events and better tolerability, avoidance of drug-drug interactions, reduced treatment costs, and improved compliance. Initial treatment should always be monotherapy. Avoidance of pharmacokinetic interactions is a major advantage. Some patients who have achieved seizure control with polytherapy may be candidates for conversion to monotherapy because there is no conclusive evidence that polytherapy provides better seizure control in the majority of patients. Recently published treatment guidelines that take into account the efficacy and tolerability profiles of new and old antiepileptic drugs (AEDs) provide recommendations for drug selection in adults. Elderly patients with epilepsy face unique treatment challenges, which include age-related reductions in liver or kidney function that may alter drug pharmacokinetics. Older persons are more sensitive to CNS side effects; some drugs may exacerbate preexisting problems such as tremor, ataxia, and cognitive difficulty. Many common conditions in the elderly are treated with drugs that are subject to interactions with AEDs. Complex dosing schedules and high drug costs are often barriers to proper care. For all these reasons, monotherapy is especially attractive for the elderly.