The main principles of
antiepileptic drug treatment of
epilepsy in patients with
intellectual disability are basically the same as for other patients with
epilepsy. However, some specific issues need to be taken into account These are primarily associated with the diagnostic difficulties of
epilepsy in this population. In addition, a number of other relevant issues, including the degree and location of brain lesion, the nature of the underlying disease, the higher frequency of difficult-to-treat
epilepsies, the additional intellectual impairment caused by inappropriate
antiepileptic medication, or by frequent and prolonged
seizures, the appropriate use of monotherapy versus rational polytherapy, and the use of broad-spectrum
antiepileptic drugs will be discussed in the present paper. Although the goals of treatment are to keep the patient seizure-free and alert while preventing possible
mental deterioration, we have to accept compromises between these primary goals in many cases. Some people with
epilepsy and
intellectual disability are very vulnerable to insidious neurotoxic effects; for example,
sedative effects caused by
phenobarbital, or cognitive and/or
cerebellar dysfunction caused by long-term
phenytoin, especially together with other drugs. Because of the adverse effects of
phenobarbital and
phenytoin, these drugs are no longer recommended as a first-choice drugs when long-term
antiepileptic medication is required. In primary
generalized tonic-clonic seizures,
valproate,
oxcarbazepine/
carbamazepine and
lamotrigine are recommended in this order of preference. The corresponding recommendations are: in typical absences,
valproate,
ethosuximide and
lamotrigine; in atypical absences,
valproate and
lamotrigine; in
juvenile myoclonic epilepsy,
valproate,
lamotrigine and
clobazam; in
infantile spasms vigabatrin,
ACTH and
valproate; in
Lennox-Gastaut syndrome,
valproate,
lamotrigine and
vigabatrin; in
atonic seizures,
valproate and
lamotrigine; in simple and
complex partial seizures with or without secondary generalization,
oxcarbazepine/
carbamazepine,
valproate/
vigabatrin and
lamotrigine; and in
status epilepticus lorazepam,
diazepam and
clonazepam together with
phenytoin or
fosphenytoin. In cases of poor response to the monotherapy recommended above, the following combinations may be indicated: in primary generalized
tonic-clonic epilepsy,
valproate and
oxcarbazepine/
carbamazepine, or
valproate and
lamotrigine; in typical absences,
valproate and
lamotrigine, or
valproate and
ethosuximide; in juvenile myolonic
epilepsy,
valproate and
lamotrigine, or
valproate and
clonazepam; and in
partial epilepsies, add to the monotherapy one of the following drugs,
vigabatrin,
lamotrigine,
gabapentin,
tiagabine,
topiramate,
zonisamide or
clobazam. So far, the order of preference of these new drugs remains undetermined. More data are needed on the efficacy and adverse effects of the new drugs based on controlled studies on patients with
intellectual disability and
epilepsy.