A CROSS SECTIONAL STUDY OF EFFECT OF ANTICONVULSANT THERAPY IN CALCIUM HOMEOSTASIS S. No Table of Content Page No 1 INTRODUCTION 2 REVIEW OF LITERATURE 3 AIMS & OBJECTIVES 4 MATERIALS & METHODS 5 RESULTS 6 DISCUSSION 7 CONSULATION 8 LIMITATIONS 9 BIBLIOGRAPHY 1
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A CROSS SECTIONAL STUDY OF EFFECT OF ANTICONVULSANT THERAPY IN
CALCIUM HOMEOSTASIS
S. No Table of Content Page No
1 INTRODUCTION
2 REVIEW OF LITERATURE
3 AIMS & OBJECTIVES
4 MATERIALS & METHODS
5 RESULTS
6 DISCUSSION
7 CONSULATION
8 LIMITATIONS
9 BIBLIOGRAPHY
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List of Tables
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Glossary Abbreviations
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INTRODUCTION
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INTRODUCTION
Epilepsy is a chronic neurological disorder affecting people of all ages and ethnicities.
Clinically it may include sudden, transient abnormal manifestations such as motor, sensory,
autonomic responses and alteration in consciousness or behavior. Seizures usually occur for a
brief duration and may cause post seizure residual effects such as an impairment in the
consciousness levels. 1
Literally, the word epilepsy is derived from the Greek root word ‘Epilambanein’. This translates
to meaning ‘to be seized’ or ‘to be overwhelmed with surprise. Mentions of epileptic disorder
can be traced back to ancient times as far as 4000 years back. Many theories had been postulated
regarding the causes and manifestation of epilepsy across various global cultures.
The manifestations of epilepsy such as the forced cry, falling to the ground, twitching, and jerky
movements have been long since thought due to caused be possession with the spirits. In some
cultures, people with epilepsy have been stigmatized, while in some others, they were thought to
be chosen or being possessed by gods. In some regions, epilepsy has even thought to be
contagious, this leading to people hesitating to touch patients of epilepsy when they have a
seizure episode. The associated stigma mostly leads to exclusion of the affected persons from
society. This has a great impact especially in the education of children and the young, further
adding on to the economic burden of the society. 2
Epilepsy has been defined by International League Against Epilepsy (ILAE; 1993) as a condition
characterized by recurrent (two or above) epileptic seizures, unprovoked by any immediate
identified cause.3 According to Cowan et al, 4(2002)
6
epilepsy is considered to be a heterogeneous group of neurological disorders characterized by
unprovoked, recurrent and paroxysmal seizure activity.
A study on the Indian perspectives regarding epilepsy was conducted by Santhosh N.S et al.
5(2014). They mention that the burden epileptic disorders among low-income countries is almost
twice than that among high income countries. In addition, the mortality due to epilepsy is higher
among low income countries, since untreated epilepsy is common. Untreated epilepsy in turn,
was often found to be associated with reduced awareness, or stigma related to the disease leading
to delays and inadequate seeking of health care.
Amudhan et al. 5(2015) continuing from the same study, mention that despite improvements in
education and social parameters over time, there has been not much significant change regarding
the stigma and discrimination in epilepsy patients. They mention that there is a vicious cycle
between economic burden and poor disease outcome among epilepsy patients.
As per the WHO estimates, epilepsy is easy to treat with daily medications that are relatively
less expensive. In both low and middle income countries, up to 70% of the patients can be
successfully treated. Even though epilepsy is mostly treatable, 75% of the people in developing
countries do not receive the treatment they require. This is called the treatment gap. This is due
to varying reasons such as lack of trained staff, reduced availability of medicines and traditions,
stigma etc. This contributes to overall mortality and morbidity among patients with epilepsy.6
Since epilepsy and its treatment are lifelong, it causes alterations in body’s physiology. One of
the major impact is on the bone mineral metabolism and Vitamin D levels. There is growing
evidence indicating the multi-pronged effect of epilepsy and anti-epileptic drugs on the bone
mineral density and serum levels of calcium, phosphate, alkaline phosphatase and Vitamin D3
7
levels. There are studies which show that (Pack A.M) patients on anti-epileptic drugs are more
prone for fractures and abnormal bone mineral metabolism.
Awareness on such factors is essential during the treatment of epileptic patients in order to
reduce lifelong morbidity and mortality. But despite the overwhelming evidence there still
remains a lack of consensus among the treating neurologists with respect to bone health and
Vitamin D levels of epilepsy patients. Studies have shown that only 28% of the adult
neurologists routinely evaluate the bone health among epileptic patients and among them only
57% refer patients to the specialists concerned. Only 7% of the neurologists routinely
supplement calcium and Vitamin D in patients on anti-epileptic drugs.7
Many studies recommend prophylactic supplementation of calcium and Vitamin D along with
regular monitoring of Vitamin D3 levels among epileptic patients on antiepileptic drugs. Yet, the
dose and standard guidelines have not been yet developed. The studies conducted so far have
been performed only in Western Countries. There is still a lack of studies assessing the bone
health of epileptic patients in developing countries such as India where the burden of epilepsy is
much higher.
Hence epilepsy as such as a major public health concern. Reducing the health complications of
epileptic patients during the course of treatment can provide an improved quality of life. Cost
effective options such as the early assessment of bone health and providing the necessary
treatment can thus reduce the complications and would be beneficial for patients suffering from
epilepsy. This study seeks to assess the same.
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AIMS & OBJECTIVES
AIMS AND OBJECTIVES:
To study the prevalence of calcium homeostasis abnormalities in patients on chronic anticonvulsant therapy.
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To access serum Vitamin D level in patients on chronic anticonvulsant therapy.
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REVIEW OF LITERATURE
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REVIEW OF LITERATURE:
Epilepsy: Definitions/ types
As per recent International League Against Epilepsy (ILAE, 2014)8, The diagnosis of epilepsy
be considered as a disease of the brain defined by any of the following conditions
At least two unprovoked (or reflex) seizures occurring >24 h apart
One unprovoked (or reflex) seizure and a probability of further seizures similar to the
general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the
next 10 years
Diagnosis of an epilepsy syndrome.
Epilepsy is considered to be resolved for individuals who either had an age-dependent epilepsy
syndrome but are now past the applicable age or who have remained seizure-free for the last
10 years and off antiseizure medicines for at least the last 5 years. "Resolved" is not necessarily
identical to the conventional view of "remission or "cure." Different practical definitions may be
formed and used for various specific purposes. This revised definition of epilepsy brings the term
in concordance with common use. 8
This above definition implies that during an episode of seizure, a large number of neurons in
the brain are activated in an abnormal way at the same time. Various etiologies can play a role in
deciding the nature of the seizure. Some of them are, the person’s age, sleep-wake cycle, brain
trauma, genetics, intake of certain drugs etc.
There have been various attempts at classifying epilepsy over time. Initially they were classified
as grand mal and petit mal seizures but they were loose terms. Then, for more than 35 years,
generalized and focal seizures were the terms used to classify. This was based on whether seizure
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activity started on one or both sides of the brain. Partial seizures in turn was classified into
simple partial and complex partial seizures depending on the presence of consciousness or
impaired consciousness respectively during the episodes.
The revised classification for epilepsy is based on three components occurring during the
episodes namely:
1. The place of origin of seizure activity within the brain
2. Level of consciousness during the episode of seizure
3. Other key features
Depending on the place of origin of seizures, seizure is classified into:
Focal seizures: Starts in the neural network in one brain hemisphere.
Generalized seizures: Both hemispheres are involved during the onset of seizures
Unknown: The place of onset cannot be found out. But later, the point of origin may
be localized.
Based on the level of awareness the patient has, during a seizure, it may be further classified into,
Focal aware: Despite a person not being able to talk or respond during a seizure, in case
their awareness remains preserved, it is called focal aware seizure.
Focal impaired awareness: If the level of awareness is affected or impaired at any point
during an episode of seizure, it is called focal impaired awareness. This persists even if
the patient retains a vague idea of what happened.
Awareness unknown: In case, the level of awareness cannot be found out from history
taking during the seizure episode, it is called awareness unknown.
14
Generalized seizures: This type of seizure episodes invariably affects the patient’s level
of consciousness to a certain extent. Hence this type does not have any specific terms to
describe seizure episodes.
Depending on the symptoms the person experiences during the seizure episodes, seizures are
further classified into:
Focal motor seizure: Some type of motor activity such as twitching, jerking or
automatisms occur during the seizure episode.
Focal non-motor seizure: Changes in sensory experiences, emotions etc. occur during the
episode.
Aura: The earliest symptoms a person may experience which herald the impending
seizure episode.
Generalized seizure on the other hand, can be classified into
Generalized motor seizure: This term corresponds to the previously used terminology
‘Generalized tonic clonic seizure’.
Generalized non-motor seizure: Absence seizures are mostly included under this
classification.
Most classification thus, are by the signs and symptoms. Additional information such as video
records, EEG, MRI scans can also be used if they are available. Genetic syndromes can also be
included in the classification. 3
Global burden of epilepsy:
The prevalence of epilepsy varies across the world and affects all ethnicities, age and gender.
Despite its global occurrence it is still under explored in many parts of this world. The World
Health Organization’s project atlas is one of the major undertakings along with the International
15
League Against Epilepsy to quantify the disease burden. The prevalence of epilepsy varies with
each country. High prevalence occurs among the adolescents and in the pediatric age group.2, 6, 9
Despite the data in prevalence, very less data is available regarding the incidence of epilepsy in
low and middle income countries. In general, the incidence rate is higher in developing countries
than among developed countries. The overall prevalence of epilepsy has been estimated to be
around 10 per 1000 persons. 10
According to the estimates by the World Health Organization (WHO), around 50 million
people all over the world are affected by epilepsy and it has been recognized as the most
common neurological disorder at the world level.
Four-fifths of the world’s population of epileptic individuals live in the low and middle income
countries such as India. Epilepsy was estimated to be responsible for 0.5% of the global burden
of disease. It accounts for 7,307,975 disability adjusted life years (DALYs) in 2005. More than
half of the world wide burden of epilepsy occurs in 39% of the population found in the
developing countries. These countries also have the highest levels of mortality.
Around 4 to 10 individuals per 1000 population have been estimated to have active epilepsy at
any point in time. This proportion can increase up to 7 to 14 in the case of low and middle
income countries. All over the world, 2.4 million people are being diagnosed with epilepsy each
year. This translates to 30 to 50 cases per 1000 population in the case of high income countries
and twice higher in low and middle income countries.
In addition, the WHO atlas in epilepsy states that the annual incidence of epilepsy ranges from
24-53 cases per 100,000 population among developed countries. In developing countries, there
are no prospective studies available for the incidence of epilepsy. The available data indicates a
16
prevalence of 49.3 to 190 cases per 100,000 population. The causative factors such as trauma,
birth defects are higher in developing countries. But the data is difficult to interpret and compare
since there is a lack of age adjustment and epilepsy usually has a bimodal peak with age.
On the world level, the incidence rates are higher among women. In developed countries, the
incidence rates are rising among the elderly and decreasing among the children. This increase in
prevalence among elderly is due to the increase in life expectancy and the consequent rise in
prevalence of cerebrovascular diseases. The decreasing prevalence among children is due to the
availability of better obstetric and neonatal care and the control of infections.
The prevalence of individuals with active epilepsy is higher among regions such as Sub-Saharan
Africa, Central and South America. The prevalence is higher among rural than in urban areas.
The reported increase in prevalence may be attributed to factors such as methodological
differences, increased consanguineous marriages and other environmental factors. Data
regarding prevalence are mainly useful for postulating the probable etiologies for epilepsy. 9
With respect to Asian countries, studies indicate that the prevalence in the country of China is
3.6 per 100 population. The prevalence was 3.65 per thousand males and 2.5 per 1000 in
females. In town areas, the prevalence was 2.45 per 1000 and rural areas, it was much higher at
3.7 per 1000 population. 11The prevalence of generalized tonic-clonic seizures was 3.12%, partial
seizures was 0.57% and unclassifiable seizures was 0.23%. The incidence rates of epilepsy range
from 28.8 per 100,000 to 35.0 per 100,000 annually.12
Studies estimate that the prevalence of epilepsy in Bangladesh is around 1.5 to 2 million. It
comes to 10 to 20 cases per 1000 population and is most common in the young adult age group
between 16 to 31 years. The prevalence is found to be somewhat higher than among the
17
neighboring countries.The prevalence is high among the males and generalized seizures is the
predominant type of seizure, similar to China. .13-15
The prevalence of epilepsy in Europe has decreased over time. Studies mention that the
prevalence of epilepsy which is 6.2 per 1000 population according to 2010 statistics, was
previously 7.1 per 1000 in 1994 and 7.6 in 1999. Generalized seizures is prevalent among 60%
of the population, 12% had mixed tonic, clonic seizures, 3% had simple partial seizures and less
than 5% had absence seizures. The incidence rate in epilepsy in United Kingdom is 47 per
100,000 population. 16-20
Among African countries, data collection is a major area of difficulty. A questionnaire survey
was conducted among the tropical countries. Based on the results, the average prevalence of
epilepsy was quite high at 15.83 per 1000 population. (M.DC) The prevalence had a high
variability ranging from 2.2 to 58 per thousand population. Sudan had a low prevalence rate at
0.9 per 1000 population.21 Active epilepsy had a bimodal peak at 20 to 29 years first when the
prevalence was 11.5 per 1000. The second peak was at 40 to 49 years of age with prevalence of
8.2 per 1000 population. Those with age 60 or more had the lowest prevalence of epilepsy at 3.1
per 1000 population. 13, 14, 22
Very few of the studies assessing the burden of epilepsy are conducted in Asian countries
despite the fact that epilepsy is highly prevalent in these regions. Mac et al.23 mention that the
estimates on the prevalence of epilepsy appear to be low in general and were collected mostly by
door to door surveys. These estimates are available for only 11 countries. Figures for yearly
incidence in countries such as China and India are similar to the developed nations such as
Europe and America, but are lower than Africa and Latin America. The peak during childhood
18
and young adult age group is similar to the developed nations, but the secondary peak at old age
is not yet reported in Asian countries.
In view of all the above studies assessing the burden of epilepsy, there are comparatively lesser
number of studies on the distribution of epilepsy based on race and ethnicity. Theodore et
al.24(2006) studied the prevalence of epilepsy comparing the African-Americans and the
Caucasians. The age adjusted prevalence of African-Americans was higher at 8.2 per 1000
compared to the Caucasians who had an age adjusted prevalence of 5.4 per 1000 population.
According to another study by Bharucha et al.25(1998) the prevalence of active epilepsy among
South Asians was comparatively lower than among non-South Asians. According to Wright et
al.26(2000), the differences in this prevalence may be attributable to multiple factors such as the
availability of preventive health care services, infrastructure and the risk of infections.
Burden of epilepsy in India:
One of the earliest studies on the epidemiology of epilepsy in India was carried out by Sridharan
R. et al.27 (1999). The overall crude prevalence was estimated to be 5.35 per 1000 population.
The adjusted prevalence was 5.59/1000. The prevalence was lower among rural (4.94/1000) than
in urban areas (6.34/1000). Men had a higher prevalence (6.05/1000) compared to women
(5.18/1000). The younger age had higher age specific prevalence rates. More than 70% in the
rural areas with epilepsy were either not receiving treatment at all or were receiving inadequate
treatment. They mention that the projected number of annual new epilepsy cases would be
around 0.5 million. This will further add on to the treatment gap existing in rural areas.
Iyer R.S et al.28 (2011) studied the primary care management practices for epilepsy among
doctors in the state of Kerala in India. They mention that very few doctors diagnosed focal
seizures and diagnostic modalities such as electroencephalograms were overused. Continuous
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anti-epileptic drug prophylaxis was prescribed for febrile convulsions and suboptimal doses were
mostly used for management of epilepsy. Most doctors were not found to be aware of alternate
management options in case of drug resistant epilepsies. Hence they recommend that educating
the primary care physicians is essential for reducing the treatment gap in case of epilepsy in
India. Moreover, educating on anti-epileptic drugs and the need based referral system were also
found to be an area of focus. There are various studies assessing the burden of epilepsy in India.
A hospital based study was conducted by Panagariya et al.29 (2014) in North-West India. They
assessed the clinical profile and the response to drug therapy among epilepsy patients a tertiary
care centre. The study was conducted over a period of 5 years. Among the patients with epilepsy
male: female ratio was 2:1. Around 62.83% of the patients were from the lower socio economic
status. Once initiated on treatment, most patients were seizure free after 2 years.
Pandey S. et al.30 (2014) conducted a study on epilepsy among the younger age group of 1 to 18
years. According to this study, the prevalence rate of epilepsy was 6.24 per 1000 population.
Febrile seizures and neurocysticercosis were the two most important etiologies of childhood
seizures. They mention the need for an effective community based approach in managing
epilepsy during childhood.
Banerjee T.K et al.31 (2015) mention that between 2003 and 2004 the overall prevalence of
epilepsy was 4.71 cases per thousand population in the region of Kolkata. The annual incidence
of epilepsy after adjusting for age was 38.3 per 100,000 population. The all cause standardized
mortality ratio due to epilepsy was 2.4. With respect to the quality of life and life expectancy,
epilepsy was responsible for 755 per 100,000 years of life lost (YLL) and 14.45 to 31.10 years of
life lost to disability (YLD) per 100,000 population. In both cases, males had higher values than
females. On the whole, the disability adjusted life years (DALY) lost due to epilepsy was 846.96
20
in 2007-08. Males had a significantly higher value of DALY at 1183.04 compared to females
(463.81) per 100,000.
Hara. H.S et al.32 (2015) conducted a population based epidemiologic study to assess the burden
of epilepsy in Punjab. They performed a door to door survey in a rural population of more than 1
lakh individuals. According to this study, the crude period prevalence of epilepsy was 7.67, and
point prevalence was 7.44 per 1000. The crude incidence rate was 60.76 per 100,000 during in
2007. In this study, there was no significant difference in active epilepsy when compared
between genders. The prevalence of active epilepsy was found to be 14.7% and symptomatic
epilepsy was 19.2%. A majority 64.5% of epilepsy cases had an undetermined cause and 1.5%
had a dual diagnosis.
Megiddo.,I. et al.33 (2016) mention that 6 to 10 million people in India are living with active
epilepsy and among them, less than 50% receive treatment. With respect to the health and
economic consequences, public financing for anti-epileptic treatments could help avert around
800,000 to 1,000,000 Disability adjusted life years in India when compared to current situation
where the majority of expenses are out of pocket. If public financing continued for 10 years,
households save more than 80 million US dollars in the form of medical expenses. They mention
that public financing for first and second line anti-epileptic drugs along with surgery is a cost-
effective and a practical option across the Indian states.
Epilepsy can be a very important public health issue among developing countries. This was
suggested by Senanayake N and G.C Roman34(1993) in a study on the epidemiology of epilepsy
among developing countries. In such countries, the prevalence of epilepsy has been estimated to
be up to 57/1000 population. In countries such as India, lack of infrastructure, infections such as
neurocysticercosis, birth injuries, road traffic accidents etc. contribute to the high burden of the
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disease. They also mention that many such risk factors are modifiable and hence there is an
increasing need for addressing this issue among developing countries.
Common etiological causes of convulsions:
Epilepsy is heterogeneous in its etiopathogenesis. The causative factors vary between developing
and developed countries due to the varying distribution of risk factors. The etiologies can be
broadly classified into genetic and acquired.
The predominantly genetic or developmental causes are:
1. Genetic mutations/polymorphisms
2. Malformations of cortical development
3. Cavernous and arteriovenous malformations
4. Neurocutaneous syndrome.
The acquired causes include:
1. Brain tumors
2. Traumatic epilepsy
3. Parasitic brain infections
4. Bacterial/viral infections of the nervous system
5. Perinatal adverse events
6. Hippocampal sclerosis
7. Cerebral immunologic disorder
8. Stroke
9. Alzheimer’s disease
Many gene mutations are associated with epilepsy, yet they still remain a minor contribution to
the proportion of epilepsy cases. Some of the strongest indications that, the risk of epilepsy
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among monozygotic twins is 62% and 18% in dizygotic twins. (Johnson, Lopes) This
concordance is significantly much more for idiopathic and symptomatic generalized epilepsy
than it is for partial seizures. This indicates that syndrome specific genetic determinants may be
operational in determining the risk of epilepsy. 35
The mechanisms involved in the genetic association with epilepsy may include death of neurons,
alteration in neuronal excitability as well as a synergism of genetics and environmental factors.
Epilepsy occurs in certain chromosomal abnormalities as well. 36
Benign or malignant brain tumors are associated a 30% incidence of epilepsy. The risk for
developing brain tumor associated epilepsy is higher among adults than in children. This depends
on multiple factors such as the grade of the tumor, location, hemispheric dysfunction or an
incomplete surgical removal of tumor.
Brain injury is yet another major cause of epilepsy. In a population based study conducted by
Hauser WA et al.37 (1993), it was reported that among 6% of the population with epilepsy, head
trauma was the causative factor. In general, around a fifth of the epilepsy cases are associated
with a history of previous brain injury.38The risk of developing epilepsy varies with the degree of
injury.
Infectious causes such as meningitis caused by viruses or bacteria is yet another etiology for
epilepsy. Despite the reduction in mortality rates over the years due to better access to health
care and immunizations, the persistence of neurologic sequelae after bacterial or viral meningitis
causes further morbidities. After bacterial meningitis, many children are left with neurologic
residual effects. Even after a year, a proportion of the children are left with onset of seizures
which were not associated with fever.39The 20-year risk of developing unprovoked seizures was
found to be 22% for those who had viral encephalitis as well as seizures early during the fever.
23
But the risk of epilepsy for those with aseptic seizures was similar compared to the general
population.40
Another more important cause of epilepsy in endemic regions such as India and South America
is neurocysticercosis. In countries such as Peru, neurocysticercosis is responsible for around 30
to 50% of all the cases of epilepsy. In these places, nearly half of the population live at the risk of
infection with Taenia solium. Calcified cysts due to neurocysticercosis are the causative agents
for epilepsy. In addition, there can be a delay between the onset of infection and the occurrence
of seizures in patients. This in turn, depends on factors such as the pathogenicity of Taenia
solium, the genetic strains and the predisposition of the host to develop epilepsy. 41, 42
Among the elderly population, one of the most important risk factors for epilepsy is stroke. One
third of the epilepsy cases among the elderly is due to stroke. Among those who have had stroke,
around 2 to 4% develop epilepsy at some point later on in life.43, 44 The risk factors for developing
epilepsy in stroke depend on several factors such as the type of stroke, the location of the stroke
and the disability caused due to it.
In a study by Bladin CF et al.45 (2000), among all patients with stroke, 8.9% developed seizures.
Among those with hemorrhagic stroke, 10.6% developed seizures and among those with
ischemic stroke 8.6% developed seizures. Recurrent seizures were present among 2.5% of the
stroke patients. Late onset of the first seizure episode was an independent risk factor for
developing epilepsy.
Another factor strongly associated with the risk of epilepsy is chronic alcohol consumption.
According to a study by Samokhvalov AV et al.46 (2010), a strong association with a relative risk
of 2.19 is found between chronic alcohol consumption and epilepsy. Moreover, the risk of
acquiring epilepsy increased with the increase in dose of alcohol consumed. Seizures among
24
alcoholics include alcohol withdrawal seizures and other seizures with mechanisms other than
withdrawal.47Many of the alcohol users with epilepsy were also found to have alcohol
dependence. Most of them experience generalized tonic-clonic seizures. 48
In developing countries like India, an important risk factor for childhood epilepsy is adverse
events occurring perinatally such as sepsis, birth asphyxia and cardiovascular insufficiency.
49Among term infants, cerebral palsy can occur in situations with or without encephalopathy.
Among those who had newborn term encephalopathy, 13% had cerebral palsy. In addition,
cognitive impairment and epilepsy were found to be common and severe among the survivors
compared to those who did not have encephalopathy during the newborn period. 50
Anticonvulsant agents:
Once a patient has been diagnosed with epilepsy and a decision has been made regarding the
starting of treatment, the choice of anticonvulsant depends on multiple factors. Some of them
include the type of seizures, the beneficial, adverse effects and the patient profile. If the drug
levels are carefully monitored and maintained at the therapeutic levels, it is possible to achieve
adequate seizure control and at the same time, minimize adverse effects. In addition, special
situations such as febrile seizures, pregnancy and status epilepticus necessitate additional
considerations as well.
Medical management of epilepsy has multiple reasons. Some types of seizures such as
generalized tonic-clonic seizures pose a significant risk of permanent brain injury or death.
Recurrent episodes of seizure is detrimental to the intellectual function. Untreated seizures
worsen with passing time and status epilepticus is associated with a 20% increased risk of
mortality. Other types of seizures such as absence seizures and partial seizures lead to temporary
decrease in the intellectual performance in addition to the risk of injury. 51
25
An ideal drug for the management of epilepsy is expected to have adequate control of seizures
without affecting the mood, sleep, intellect, physical performance and arousal response. Since
epilepsy is the result of neurons firing abnormally in the brain, it is difficult to find a drug that
selectively affects neurons causing seizures while sparing the normal neurons. In some instances,
there needs a trade-off between achieving seizure control and minimizing the adverse effects of
drugs.
Classification:
According to the structural chemistry, the anti-epileptic drugs may be classified as follows:
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ANNEXURES
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