Achieving rational management for patients with refractory epilepsy can be difficult. We audited our management of 55 patients with refractory epilepsy by comparing two 3-month periods each 9 months apart. Despite attempts to rationalize antiepileptic drug therapy, a smaller proportion of patients were managed with monotherapy by the second analysis (16% vs 22%); however fewer patients were taking three or more AEDs (28% vs 43%). A substantial impact on seizure frequency was made in only six patients whilst 22 patients had a significant deterioration in seizure number (P = 0.005). Monitoring of AED levels was of little value with only six clinical decisions based on 305 AED levels performed at a cost of 2525 pounds. The newer AEDs accounted for a disproportionate expenditure (65% of the total AED cost in the second 3-month period) considering their lack of therapeutic impact. We confirm the need for audit in this patient group to ensure that pre-defined targets are met.