epilepsy treatment

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


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


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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epilepsy treatment

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