Flashcards in OHCM - Epilepsy: Management Deck (32):
Absence seizures - Give:
Tonic, atonic, and myoclonic seizures - Give:
As for generalized tonic-clonic seizures, but avoiding carbamazepine and oxcarbazepine, which may worsen seizures.
Partial seizures +/- secondary generalization - Give:
1st line = Carbamazepine.
2nd line = Valproate, lamotrigine, oxcarbamazepine or topiramate.
Others: Levetiracetam, gabapentin, tiagabine, phenytoin, clobazam.
Treat seizures with one ... and one ... .
ONE DRUG - ONE DOCTOR IN CHARGE.
To switch drugs:
Introduce the new drug, and only withdraw the 1st drug once established on the 2nd.
Dual therapy is necessary in
Consider if all appropriate drugs have been tried singly at the optimum dose.
Cannot exclude or refute epilepsy!
Non-epileptic attack disorder (pseudo- or psychogenic seizures):
These are NOT INFREQUENT.
Suspect this if there are uncontrollable symptoms, no learning disabilities, and CNS exam, CT, MRI, and EEG are normal.
Non-epileptic attack disorder (pseudo- or psychogenic seizures) - May coexist with ...?
If drugs don't work ...?
If a single epileptogenic focus can be identified such as hippocampal sclerosis or small low-grade tumor, neurosurgical resection offers up to 70% chance of seizure freedom, depending on the location of the focus, with the risk of causing focal neurological deficits such as memory impairment, dysphasia, or hemianopia.
--> An alternative is VAGAL nerve stimulation, which can reduce frequency and severity in 33%.
When it all goes wrong ...?
Sudden unexpected death in epilepsy (SUDEP) is more common in uncontrolled epilepsy, and may be related to nocturnal seizure-associated apnea or asystole.
Those with epilepsy have a mortality rate ...?
3-fold that of controls.
>... epilepsy-related deaths are recorded/yr in the UK.
700 (17% are SUDEPs).
Carbamazepine (as slow release):
Initially 100mg/12h --> increase by 200mg/d every 2wks up to max 1000mg/12h.
Carbamazepine - SE:
2. Diplopia/blurred vision.
3. Impaired balance.
5. Mild generalized erythematous rash.
Lamotrigine - Doses:
As monotherapy, initially 25mg/d --> incr. by 50mg/d every 2wks up to 100mg/12h (max 250mg/12h).
--> Halve monotherapy dose if on valproate; double if on carbamazepine or phenytoin (max 350mg/12h).
Lamotrigine - SE:
1. Maculopapular rash - occurs in 10% (but 1/1.000 develops SJS or TEN) typically in first 8wks, especially if on valproate; warn patients to see a doctor at once if rash or flu symptoms develop; also associated with hypersensitivity (fever, incr. LFTs and DIC).
2. Diplopia/blurred vision.
3. Photosensitivity (SLE-like).
4. Tremor, agitation.
6. Aplastic anemia.
Levetiracetam - Doses:
If >16yrs, initially 250mg/24h --> increase by 250mg/12h every 2wks up to max 1.5g/12h (if eGFR >80).
Levetiracetam - SE:
7. Blood dyscrasias.
Effective and well-tried, but no longer 1st-line for generalized or partial epilepsy due to toxicity.
Phenytoin - SE:
5. Decr. intellect/depression.
6. Coarse facial features.
8. Gum hypertrophy.
10. Blood dyscrasias.
Phenytoin - Doses:
Difficult - do blood levels.
Valproate - Doses:
Initially 300mg/12h --> Increase by 100mg/12h every 3 days up to max 30mg/kg (or 2.5kg) daily.
Valproate - Why take with food?
Nausea is very common.
Valproate - SE:
Appetite UP, weight gain.
Liver failure (watch LFTs esp. during 1st-6months).
Reversible hair loss (grows back curly).
Teratogenicity, tremor, thrombocytopenia.
Encephalopathy (due to hyperammonemia).
Only used in infantile spasms (due to high incidence of visual field defects).
Teratogenicity of anti-epileptic drugs - Women of child-bearing age should ...?
Folic acid 5mg/d.
Avoid valproate (use lamotrigine).
Most AEDs are present in breast milk, carbamazepine and valproate.
Lamotrigine is NOT thought to be harmful to infants.
Most patients are seizure-free within a few years of starting the drugs. More than ...% remain so when the drugs are withdrawn.
More than 50%.
Withdrawal may be tried, if the patient meets the criteria:
1. Normal CNS exam.
2. Normal IQ.
3. Normal EEG prior to withdrawal.
4. Seizure-free for >2yrs.
5. No juvenile myoclonic epilepsy.
One way to withdraw drugs in adults is to decrease the dose by ...?
10% every 2-4wks - for carbamazepine, lamotrigine, phenytoin, valproate, and vigabatrin.
10% every 4-8wks - for phenobarbital, benzodiazepines, ethosuximide.