Epilepsy CurrentsBeyond the First Pill and the First Year: Rethinking Treatment Response in Newly Diagnosed Focal Epilepsy

🎓 Expert Commentary / Peer Perspective

An expert commentary interprets the Human Epilepsy Project cohort, which followed newly diagnosed focal epilepsy across 34 centers. Most patients needed over a year and more than one antiseizure medication to reach seizure freedom.

Clinical Considerations

• Roughly 60% achieved seizure freedom, mostly without relapse, but only 1 in 4 became seizure-free on their first medication.
• In the first year, 63% had ongoing or worsening seizures; early persistence did not reliably predict long-term drug resistance.
• Psychiatric comorbidities raised resistance risk 1.78-fold; frequent pretreatment seizures also predicted resistance.
• The commentary questions levetiracetam as default first-line, noting most resistance emerged within 6 to 8 months.

Practice Applications

• Recognize that early ongoing seizures do not confirm drug resistance.
• Monitor patients with psychiatric comorbidity or frequent seizures more closely.
• Consider alternative first-line agents over reflexive levetiracetam selection.
• Integrate earlier specialist referral when suboptimal response appears.