Failure of "rational" antiepileptic drug therapy

We report the case of ameanwhile 71-year-old female patient with an idiopathic generalized epilepsy syndrome with myoclonic and generalized tonic-clonic seizures and extensive photoparoxysmal response (PPR) grade 4 according to Waltz. The patient did not become seizure-free over many years in spite of the usual antiepileptic drug (AED) regimens and prophylactic protective arrangements to reduce the impact of photic stimulation. The patient had participated in aprevious proof-of-concept study in which the effect of a single dose of brivaracetam (BRV) on the PPR of photosensitive epilepsy patients was tested, long before the approval studies. In this study the patient showed aconvincing positive effect of asingle dose of BRV on the PPR. Therefore, the patient was treated with BRV after its approval for treatment of epilepsy for patients with focal and secondary generalized tonic-clonic seizures in the sense of an off-label approach. The maximum add-on dose was 200mg per day. Unfortunately, this rational therapeutic approach failed because the PPR and the frequency of generalized tonic-clonic seizures were not suppressed. This case experience suggests that results of asingle-dose study in patients with PPR do not necessarily predict the long-term potential of agiven AED even on an individual basis.