Clinical trials for therapeutic assessment of antiepileptic drugs in the 21st century: obstacles and solutions

Clinical trials as part of antiepileptic drug development are increasingly expensive and complex, with many pitfalls that can derail even promising drugs and devices. Although a third of patients remain resistant to treatment, the availability of more than 20 approved antiepileptic drugs can reduce the incentive to enrol in trials of unproven agents, for which safety is not assured. The challenge of recruiting patients drives investigators to regions of the world where treatment options are more limited. This increases complexity and has potential implications for quality of the trial data. Furthermore, the availability of so many approved treatments raises questions about the ethics and safety of placebo-controlled trials in patients with epilepsy. Novel trial designs, such as time-to-event adjunctive therapy and historical-control monotherapy, might be more acceptable to patients and their doctors because they restrict exposure to placebo or ineffective treatments.