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Am Fam Physician. 2018;98(1):10-11

Original Article: Epilepsy: Treatment Options

Issue Date: July 15, 2017

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To The Editor: Thank you for your summary of treatment options for epilepsy. However, we wanted to clarify the evidence regarding the ketogenic diet. As many as one-third of patients have refractory epilepsy that is not easily controlled with medication. Studies have shown that patients who are not seizure-free with adequate dosing of an initial drug will only have their epilepsy controlled 10% of the time by adding a second medication.1,2 Also, antiepileptic medications have considerable cognitive, mood, oral health, and dermatologic adverse effects.

The ketogenic diet has been used in patients with drug-resistant epilepsy since the 1920s. Most major hospital centers offer multidisciplinary ketogenic programs. Randomized controlled trials demonstrate that these diets result in more than 50% reduction in seizures with small populations becoming seizure free.3 In 2008, the International Ketogenic Diet Study Group published clinical management guidelines for effective nonpharmacologic treatment of intractable childhood epilepsy.4 Adverse effects from the ketogenic diet, including constipation and kidney stones, are preventable, and a survey of patients found 96% would recommend it to others.5

When two or three antiepileptic medications have been ineffective, the ketogenic diet should be considered as a treatment option. It is especially useful in Dravet syndrome, infantile spasms, myoclonic-astatic epilepsy, and tuberous sclerosis complex. The ketogenic diet is the treatment of choice for seizures from glucose transporter type 1 deficiency and pyruvate dehydrogenase deficiency syndromes.4 It is important for family physicians to understand the limitations of medications for these patients, and the effective alternatives.

In Reply: We agree that the ketogenic diet may be tried if seizures are not well-controlled after attempting pharmacologic management. The literature suggests that the ketogenic diet might be helpful in certain types of seizures, but this is based on limited evidence.1 Limitations include variability of inclusion criteria and small cohorts. We appreciate the work of the Charlie Foundation and the International Ketogenic Diet Study Group to identify areas where the ketogenic diet could be utilized.2 However, these guidelines are strongly grounded in expert opinion due to the lack of robust trials.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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