Indications for polytherapy
1. Multiple seizure type
2. Failure of adequate trial with monotherapy with AEDs

Principles of polytherapy
1. Use appropriate and *rational drug combinations (eg.) valporic acid (VPA), LTG, VPA & CLBZ have synergistic action. PB and PHT are enzyme inducers and reduce levels. PB and BZD increase side effects like drowsiness.
* Rational denotes using not more than 2 drugs at a time and avoiding drugs with similar mechanism of action. PB, BZDs, PHT and CBZ.
2. Exclude progressive/severe neurological disease.

Other Therapeutic modalities
a. Ketogenic diet
b. Vagal stimulation
c. Surgery

Duration of therapy
The duration of AED therapy is for 2 years of seizure free period.

AED withdrawal
Gradual tapering AEDs over 6-12 weeks is adequate. Long duration tapering periods do not decrease the risk of seizures.

Patient follow up

Initially the patient visit should be 2 to 4 weekly depending on seizure frequency. Subsequently the patient is followed up every 3 to 6 monthly. Dosage adjustments

should be made as per the gain in the weight of the growing child. There is no need to monitor blood counts with CBZ and liver functions with VPA for bone marrow and liver toxicity respectively. Monitoring blood levels of the drug may be useful only in status epilepticus to confirm toxicity, and also to rule out non compliance.

Long term remission
Relapse risk ranges from between 20-30% and is maximum (70-80%) in the first year of discontinuation of therapy.
Factors predicting the long term remission are as follows:
a. Normal intelligence
b. Normal neurologic examination,
c. Relatively small number of seizures at diagnosis
d. Shorter duration
e. Age at onset between 1 and 12 years.
f. Absence of a remote symptomatic etiology

Family and social awareness

• The parents are encouraged to educate the teacher on first aid measures and even keep rectal diazepam at school.
• Neighbours, family members and friends, where the child spends substantial time must also be informed
• Supervise activities like swimming, cycling etc rather than imposing restriction.
• Girls should stay away from kitchen stoves.
• The supervision should continue for at least a year after seizures are in remission.
• Down playing the parents anxiety and avoiding over protection is also necessary.