Management of EPILEPSY

Shilpa Kathuria
060202353

PRINICIPLES OF TREATMENT
Treatment of underlying conditions

Avoidance of precipitating factors

Antiepileptic drug therapy Surgery for refractory epilepsy Addressing psychological and social issues Individualize treatment plan ( because of different types and causes of epilepsy and efficacy+ toxicity of drugs differ)

Treatment of underlying conditions

Metabolic disturbance e.g. abnormal levels of serum electrolytes and glucose : treat to prevent recurrence.

Medication( e.g. theophylline) or drug use (cocaine): avoid drugs

CNS lesion e.g. brain tumor or abcess : remove them but de novo seizure focus may remain so give drugs for atleast 1 year.

Avoidance of precipitating factors

Sleep deprivation : advise to maintain sleep schedule. Alcohol intake : modify drinking habits Stress : meditation, counseling.

Antiepileptic drug therapy

GOAL: Prevent seizures without causing side effects Preferably use single medication Compliant dosing schedule

Indications for initiation of drug therapy

Recurrent seizures of unknown cause/ known cause that is irreversible.

Risk factors for recurrent seizures: Abnormal neurological examination

Status epilepticus Post ictal todds paralysis

Family history of seizures

Abnormal EEG If 1 or >1 risk factor present treat.

Name Phenytoin Carbamazepine

Use Tonic clonic (grand mal), focal onset Tonic clonic, focal onset Tonic clonic Absence, myoclonic Focal onset Focal onset Tonic clonic, myoclonic Lennox gastaut syndrome

Dose 300-400mg/day 600-1800mg/day

Valproic acid

750-2000mg/day

Lamotrigine

150-500mg/day

Name

Adverse Effects Neurologic Systemic Gum hyperplasia Hirsutism Osteomalacia

Drug interactions

Phenytoin

Dizziness Diplopia Ataxia

Level by isoniazid,sulfonami de. Level by carbamazepine

Carbamazepine

Dizziness Diplopia Ataxia Ataxia Tremor Dizziness Diplopia

Aplastic anemia Level by phenytoin Leucopenia hepatotoxicity Level by isoniazid,

eryhtromycin
Valproic acid lamotrigine

Hepatotoxicity Level by phenytoin platelets

Steven johnson Level syndrome :phenytoin,OCP

valproate

Initiation and monitoring of drug therapy

Determination of optimal dose by trial and error. Drugs started slowly with lowest possible dose. Patients should expect s/e :mild sedation, imbalance, changes in cognition.

Monitoring can be done by measuring serum drug levels but clinically by measuring seizure frequency and presence of side effects. Free drug levels correlate best with efficacy.
If seizures persist even after to maximum tolerant dose start patient on 2nd drug and gradually withdraw 1st drug.

Discontinuation of therapy
Complete medical control of seizures for 1-5 yrs. Single seizure type- partial/generalized. Normal neurological examination including intelligence. Normal EEG. If Above criterias are met, patient is motivated to discontinue the treatment, should understand risks/benefits

Attempt to withdraw drug over 2-3 months after 2 yrs of therapy.

Treatment of refractory epilepsy

Epilepsy which does not respond to treatment with single drug.

What to do in such case??

Polypharmacy i.e. combination of drugs with different mechanisms. Most cases initial therapy combines 1st line drugs. (phenytoin, carbamazepine). If not successful add newer drugs e.g. topiramate. E.g. patient of absence seizures (refractory) may respond to combination of valproate and ethosuximide.

Status epilepticus
Continuous or repetitive discrete seizures lasting for 15-30 min with impaired consciousness in inter ictal period. Practically duration of seizures which prompts acute treatment. Types 1. Generalized convulsive status epilepticus (GCSE) 2. Nonconvulsive status epilepticus (e.g. persistent absent/partial seizures)

Immediate care of seizures

Women and epilepsy

CATAMENIAL EPILEPSY: in seizure frequency around menses. Treatment :1. dosage of antiepileptic drug 2.control of menstrual cycle by OCP 3. acetazolamide(250-500mg/d)1 week prior to menses.

PREGNANCY : fetal abnormalities possible Treatment : 1. monotherapy at lowest effective dose 2. folate(1-4 mg/day) 3. mother : oral vitamin K (20mg/day) in last 2 weeks of pregnancy infant : vitamin K(1mg) at birth.

 CONTRACEPTION Advise alternate contraceptive methods as antiepileptic drugs antagonize OCP effect by enzyme induction (e.g. carbamazepine, phenytoin) BREAST FEEDING no long term harm to infant by being exposed to antiepileptic drugs through breast milk so encourage mother to feed not stop.