Place of polytherapy in the early treatment of epilepsy

Polytherapy with antiepileptic drugs is not popular mainly because it is thought to be associated with more adverse effects and to contribute relatively little in terms of efficacy compared with monotherapy. However, there are two reasons to question this assumption: (i) certain combinations are more effective than others and, therefore, generalisations about the poor effectiveness of polytherapy cannot be made; and (ii) the total drug load, i.e. the total amount of drug exposure for a certain indication, is usually higher in polytherapy, which may explain the higher toxicity seen during such treatment. In this article, the available literature on the effectiveness of first-line monotherapy, alternative monotherapy and second-line polytherapy is reviewed. There is no conclusive evidence in favour for choosing either alternative monotherapy or polytherapy when first-line monotherapy fails. Therefore, a pragmatic approach is recommended until an evidence-based choice can be made.