DAY 1 | Patients and Providers Struggle with the Complex Titration Schedules of Anti-Seizure Medications

The titration of anti-seizure medications presents a complex clinical challenge for patients with focal epilepsy and the physicians who manage their care, according to findings from a study presented at the 2025 American Epilepsy Society Annual Meeting, in Atlanta, Georgia.

Guidelines recommend slow titration of most anti-seizure medications to improve tolerability, resulting in complex medication schedules that may be hard to manage and that patients may find confusing. Data reflecting the perspectives of both patients and healthcare providers revealed that medication titration complicates the management of epilepsy and increases the strain on healthcare resources. Responses collected from epileptologists and patients also showed that titration is rarely part of the doctor-patient dialogue. 

In January 2025, a cross-sectional online survey was sent out to patients with a physician-confirmed diagnosis of focal onset seizures (FOS). The 48 respondents selected for the final analysis had tried and failed at least one anti-seizure medication within the past year and had used anti-seizures medications requiring titration or dose escalation or modification within the past year. Patients with a history of psychogenic non-epileptic seizures, Dravet syndrome, Lennox–Gastaut syndrome, or other developmental and epileptic encephalopathies were excluded. The researchers collected data regarding demographic characteristics, clinical history, and epilepsy-specific quality-of-life measures. The survey also asked about factors influencing the choice of medication, adherence, side effects, dose modifications, healthcare resource utilization, and challenges experienced during titration. 

Additionally, the study included the feedback of seven U.S.-based epileptologists who were treating a mean number of 95 patients with FOS per month at academic hospitals and had experience prescribing anti-seizure medications that required titration. Physicians reported that cross-titration, the process of decreasing the dose of one drug while simultaneously increasing the dose of another drug when switching between medications or initiating combination therapy, adds another layer of complexity to clinical management. The providers also reported that that complex dosing schedules are associated with unpredictable outcomes and can negatively impact adherence.

Patients with FOS reported various concerns during the titration of their medications, including worry about having focal seizures during titration (56%) and not having a clear understanding of the titration process (35%).  Nearly one-quarter of the respondents admitted that they were uncomfortable talking to their healthcare providers about the titration process. Only 17% of the patients reported no concerns during the titration process.

According to the participating physicians, the titration of anti-seizure medications also increases the strain on healthcare resources. The providers pointed out issues such increased reliance on clinic staff to triage calls and provide patient support, higher volumes of patient communication, and more frequent follow-up clinic visits to monitor patients during titration. “There's a lot of micro-management that has to be done,” one participating physician noted. “And the process is going to take at least 6 months to a year to try to get to the target. It is very slow and labor-intensive, for sure.” 

Semi-structured interviews about practices and perspectives across the titration process showed that the providers previously viewed titration as routine and may not have fully appreciated the challenges experienced by patients. All participating physicians agreed that the burden of titration is generally underrecognized. One provider noted that, while the titration process may seem straightforward to an experienced physician, it may constitute unfamiliar territory for most patients. The patients’ responses were consistent with the physicians’ observations regarding the underrecognized burden of titration. Many patients worried about breakthrough seizures and reported difficulty keeping up with dose adjustments and understanding the titration steps. 

During a scientific poster session, the authors noted that new agents that are being studied for the treatment of focal epilepsy have the potential to simplify regimens and reduce the need for titration and cross-titration. “These findings underscore the substantial and potentially overlooked burden associated with anti-seizure medication titration on patients and physicians, highlighting the need for improved communication between patients and physicians, as well as the need for anti-seizure medications that require simplified or no titration,” they concluded.