Epilepsy and Seizures Treatment & Management Dr. Md Rashedul Islam FCPS, MRCP(UK) Registrar, Neurology, BIRDEM
Epilepsy and Seizures Treatment & Management
Dr. Md Rashedul Islam
FCPS, MRCP(UK)
Registrar, Neurology, BIRDEM
Epilepsy is defined as a brain disorder characterized by an enduring predisposition to generate epileptic seizures and by the neurobiologic, cognitive, psychological, and social consequences of this condition.
Approach Considerations
The goal of treatment in patients with epileptic seizures is to achieve a seizure-free status without adverse effects
Monotherapy is desirable because it decreases the likelihood of adverse effects and avoids drug interactions.
People with seizures experience psychosocial adjustments after their diagnosis; therefore, social and/or vocational rehabilitation may be needed
Classification of Seizures
Focal seizures
(Can be further described as having motor, sensory, autonomic, cognitive, or other features)
Generalized seizures Absence Typical Atypical Tonic clonic Clonic Tonic Atonic Myoclonic
May be focal, generalized, or unclear
Epileptic spasms
Anticonvulsant Therapy
Anticonvulsants can be divided based on their
mechanisms. Blockers of repetitive activation of the sodium
channel: Phenytoin, carbamazepine, oxcarbazepine, lamotrigine, topiramate
Enhancers of slow inactivation of the sodium channel: Lacosamide, rufinamide
Gamma-aminobutyric acid (GABA)–A receptor enhancers: Phenobarbital
N -methyl-D-aspartic acid (NMDA) receptor blockers: Felbamate
Anticonvulsant Therapy
Alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA) receptor blockers: topiramate
T-calcium channel blockers: Ethosuximide, valproate
N- and L-calcium channel blockers: Lamotrigine, topiramate, zonisamide, valproate
H-current modulators: Gabapentin, lamotrigine Blockers of unique binding sites: Gabapentin,
levetiracetam
Adverse Effects of Commonly Used Antiepileptic DrugsDrug Principal use Adverse effects
Valproic acid Tonic-clonicAbsenceAtypical absenceMyoclonicFocal-onsetAtonic
AtaxiaSedationTremorHepatotoxicityThrombocytopeniaGastrointestinal irritationWeight gainTransient alopeciaHyperammonemia
Adverse Effects of Commonly Used Antiepileptic DrugsDrug Principal use Adverse effects
Carbamazepine UsesTonic-clonicFocal-onset
AtaxiaDizzinessDiplopiaVertigoStevens johnson syndromeAplastic anemiaLeukopeniaGastrointestinal irritationHepatotoxicityHyponatremia
Adverse Effects of Commonly Used Antiepileptic Drugs
Drug Principal use Adverse effects
Levetiracetam Focal-onsetGTCS
SedationFatigueIncoordinationMood changesAnemiaLeukopenia
Adverse Effects of Commonly Used Antiepileptic DrugsDrug Principal use Adverse effects
Oxcarbazepine Focal-onsetTonic-clonic
FatigueAtaxiaDizzinessDiplopiaVertigoHeadacheAplastic anemiaLeukopeniaGastrointestinal irritationHepatotoxicityHyponatremiaHypersensitivity
Nonpharmacologic Management
Ketogenic diet and modified Atkins diet Vagal nerve stimulation Implantable neurostimulator
Surgery for drug-resistant epilepsy
Although surgery for drug-resistant epilepsy is often considered a last resort, results of a multicenter trial suggested that early surgery may be helpful in some patients with newly intractable and disabling temporal lobe epilepsy
Anticonvulsants in Specific Patient PopulationsWomen on contraceptive agents:
Anticonvulsants induce hepatic enzymes, such as carbamazepine, phenytoin,lamotrigine, topiramate, and oxcarbazepine leading to contraceptive failure
Some obstetricians use a high-dose estrogen-progesterone contraceptive to counteract this effect
An alternative and possibly preferable approach is to use a second method of contraception
Women of childbearing age and pregnant women
Woman of childbearing age should take folic acid, at least 0.4 mg per day
During pregnancy, women should take the medication that best controls their epilepsy
Switching medications during pregnancy is not recommended, because of the risk of losing seizure control and because it exposes the fetus to polypharmacy
Women of childbearing age and pregnant women
Data from multiple studies show an exponential risk of birth defects as anticonvulsants are added in polytherapy.
Frequent drug serum levels should be obtained because of the many physiologic changes that take place during pregnancy
In particular, decreased serum concentration of lamotrigine in the third trimester is well documented, and the dose needs to be adjusted after delivery
Patients with hepatic and renal insufficiency
Gabapentin, pregabalin, levetiracetam, and lacosamide are excreted mostly by means of renal clearance, and their doses can be adjusted for renal insufficiency. These agents are useful in patients with hepatic failure
Among all anticonvulsants, phenytoin, carbamazepine, valproic acid, and felbamate have been associated with acute hepatic injury.
Risk of seizure recurrence
Several seizure types (eg, worse if tonic or atonic seizures are present)
High number and frequency of seizures Long duration of epilepsy before the seizures
were controlled
Discontinuing Anticonvulsant Agents
The following patient profile yields the greatest
chance of remaining seizure free after drug
withdrawal:
1. complete medical control of seizures for 1–5 years
2. single seizure type, either focal or generalized
3. normal neurologic examination, including intelligence
4. normal EEG.
Discontinuing Anticonvulsant Agents
The appropriate seizure-free interval is unknown and undoubtedly varies for different forms of epilepsy
It seems reasonable to attempt withdrawal of therapy after 2 years in a patient who meets all of the above criteria, is motivated to discontinue the medication, and clearly understands the potential risks and benefits
In most cases it is preferable to reduce the dose of the drug gradually over 2–3 months
Activity Modification and Restrictions
The major problem for patients with seizures is the unpredictability of the next seizure. Clinicians should discuss the following types of seizure precautions with patients who have epileptic seizures or other spells of sudden-onset seizures:
Driving Ascending heights Working with fire or cooking Using power tools or other dangerous equipment Taking unsupervised baths Swimming
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