Treating Patients Who Are Unresponsive to Therapy

An expert in the management of epilepsy provides advice for community neurologists on how to care for patients who are unresponsive to therapy, and when to refer them to a specialty center. 

Trevor Resnick, MD: One of the questions that I get from a lot of my colleagues in the community, community neurologists who take care of patients with epilepsy and do a very good job, is they call sometimes saying, “Look, would you please take over this patient’s management because I’m having a really difficult time controlling their seizures, and I’ve tried 2 or 3 different medications.” Or, “I’m really not sure what seizure type they have. I’ve done X, Y, and Z testing, and I’d like your input as well.”

Then the question comes up, “Do different neurologists have different thresholds for when they need another person thinking about the case?” I think that if you look at the natural history of patients who present with new onset epilepsy, 60% of patients approximately who present with new onset seizures are either controlled with a first or the second antiepileptic drug. I think under those circumstances certainly community urologists have no reason to need to refer those patients to an epilepsy center or for another opinion.

The second they get past that point, then you’re getting down the path where of the remaining patients who have not responded to those 1 or 2 antiepileptic medications, then you’re dealing with a very low response rate in terms of getting seizures under control. That’s where I think it’s a good idea under those circumstances, not necessarily to hand the patient over to someone else, but to get another opinion to see what are a series of different options, and are those series of different options different than me as a general neurologist? I think that’s one scenario where that’s a reasonable way to think it through.

Another scenario is, a patient presents with seizures and you do the usual testing, and it doesn’t help you, and you’re still stuck with just a descriptive diagnosis of the fact that the patient either has a partial seizure or a generalized seizure, and you’re thinking, is there something here that I’m missing? Could this patient have a genetic mutation? Could this patient have some other kind of syndrome that’s unusual or that I haven’t thought of?

I think under those circumstances where the presentation is puzzling and it doesn’t fit, that’s another scenario where a community neurologist may want to say, “Look, there’s something unusual with this case. Let me get a second pair of eyes to look at it.”

Then there are a group of patients who I think have been treated with a number of different antiseizure medications. And they get to the point where there’s a different level of complex management that is necessary, whether it’s evaluation for epilepsy surgery, or different types of techniques or combinations of medications. And that’s where it also warrants getting a referral to an epilepsy center.