Should a trial of cenobamate (Xcopri) be required before referring a patient for epilepsy surgery?

First, I would like to declare my conflict of interest that I am a speaker for Xcopri/SK Life. That being said, I only speak for things I truly use and believe in.

My general teaching to learners is this (not saying there cannot be exceptions): I would not use Xcopri first line because there are better tolerated meds out there. At the very least, Xcopri should be used as a third-line agent, as a 20% seizure free rate is clearly better than 2-4% for any other med. One could debate about using it as a second line, but I'll leave that for debate (I personally present the data to the patient and let them choose).

Now, if a patient has not trialed Xcopri, should they be REFERRED for epilepsy surgery? This question is raised because surgery has a...

Thank you for bringing forward this important and timely topic. While perspectives may reasonably differ regarding the optimal role and timing of additional antiseizure medication trials in individual patients, there is broad agreement within the epileptology community that favorable surgical candidates - whose goal is to become and remain seizure-free thereby eliminating their substantially higher risk for SUDEP in addition to all the well-recognized accompaniments of uncontrolled seizures - should undergo epilepsy surgery without delay as earlier intervention is associated with substantially higher rates of seizure freedom and avoidance of the cumulative cognitive, psychosocial, and medical consequences of ongoing seizures (Bjellvi et al....

It’s not cenobamate vs. surgery. It can be both. I start all candidates for surgery at the time of their Video-EEG if they are not taking the medication already. If and when they become seizure-free, I use that period to prepare them for a life without seizures. If they are not working, I refer them for a vocational evaluation since the stronger predictor for working after surgery is working before surgery.

Furthermore, 70% of patients will experience a remission of focal to bilateral tonic clonic seizures and a > 60%-70% reduction in seizure frequency.

Finally, in our experience with more than 200 patients treated with cenobamate who achieved seizure freedom for 12 months, 15% had seizure recurrence.