Epilepsy management

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  • Created by: MazzaW
  • Created on: 07-12-19 15:40

Minimising epileptogenic stimuli

Stimuli:

  • fever
  • flickering lights
  • lack of sleep
  • alcohol abuse
  • epileptogenic drugs
  • abrupt withdrawal of medications
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Idiopathic generalised epilepsy

1st line:

  • sodium valproate
  • lamotrigine if woman of child-bearing age- may exacerbate myoclonus
  • consider carbamazepine/oxcarbazepine- may eacerbate myoclonus

Adjunctive Rx: clobazam, lamotrigine, levetiracetam, sodium valproate, topiramate

If myoclonus/absence seizures, do not offer: carbamazepine, gabapentin, oxcarbazepine, phenytoin, pregabalin, tiagabine, vigabatrin

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Absence seizures

1st line: ethosuximide (if absences only) or sodium valproate (lamotrigine if others not suitable/ tolerated)

2nd line: clobazam, clonazepam, levetiracetam, topiramate, zonisamide

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Myoclonus

1st line: sodium valproate (levetiracetam/topiramate if unsuitable/not tolerated)

Adjunctive Rx (after discussion with tertiary centre): clobazam, clonazepam, piracetam, zonisamide

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Partial seizures

1st line: lamotrigine or carbamazepine

If above contraindicated: levetiracetam, oxcarbazepine, sodium valproate

2nd line: alternative from above

Adjunctive Rx as above OR clobazam, topiramate, gabapentin

2nd line adjunctive Rx: eslicarbazepine, lacosamide, phenytoin, phenobarbital, pregabalin, tiagabine, zonisamide, vigabatrin

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Adverse effects of antiepileptics

  • acute allergic reaction e.g. skin rash
  • toxic effect e.g. unsteadiness, blurred vision, tremor, confusion
  • teratogenicity e.g. spina bifida
  • chronic adverse reactions: weight gain/loss, hair loss, overgrown gums, memory loss, behavioural disturbances, mood changes, anaemia, osteomalacia
  • interactions with other drugs

Specific drugs:

  • sodium valproate: weight gain, tremor, Parkinsonism, teratogenicity
  • carbamazepine/lamotrigine/phenytoin/lacosamide: tiredness, double vision, unsteadiness
  • topiramate/zonisamide: weight loss, behavioural changes, renal stones, paraesthesiae
  • levetiracetam: tiredness, dizziness, aggression
  • clobazam/clonazepam: sedation
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Prescribing antiepileptics

  • start with low dose of 1st line drug
  • gradually increase dose until adverse effects or seizure free

If seizures fail to respond:

  • reconsider diagnosis
  • add new 1st line drug and taper original drug
  • start 2nd line drug and withdraw original drug if possible
  • only use polytherapy if monotherapy ineffective
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Contraception and antiepileptics

Carbamazepine, oxcarbazepine, eslicarbazepine, phenobarbitone, phenytoin, primidone, topiramate all interfere with COCP (CYP450 inducers):

  • need COCP containing at least 50mcg oestrogen e.g. Femodette + Femodene, Marvelon + Mercilon, Microgynon 30 x2, Loestrin 20 + Loestrin 30
  • tricycle: take 3 pill packs then 4 days off, if have breakthrough bleeding then contraception is ineffective
  • avoid Implanon implants, progesterone-only pill and contraceptive patches
  • Mirena coil and Depo-Provera can be used
  • need increased dose of emergency contraception

COCP causes decreased levels of lamotrigine

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Indications for monitoring drug levels

  • as a guide for dosing (especially phenytoin)
  • to check compliance
  • ?toxic symptoms
  • to monitor pharmacokinetic interactions
  • during pregnancy
  • in learning disabled/acutely ill
  • AEDs in which monitoring may be helpful: phenytoin, carbamazepine, lamotrigine, ethosuximide, phenobarbital
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Status epilepticus

  • ABCDE
  • secure airway and give O2 (may need to intubate), cardiac monitoring, oximetry
  • give glucose, thiamine and maintain AEDs
  • collateral history if possible
  • IV lorazepam 0.07mg/kg (or 4mg), repeat once after 10-20mins if necessary OR diazepam 10-20mg up to max 40mg
  • give phenytoin 15-18mg/kg in new patient over 20-30mins (0.5-1g if already on phenytoin)
  • watch for hypotension/arrhythmias
  • if further seizures: consider phenobarbital/propofol/midazolam/thiopental and transfer to ITU
  • bear in mind possibility of non-epileptic status

Avoidance: treat serial seizures (e.g. clobazam), treat prolonged seizures (e.g. buccal midazolam)

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SUDEP

Sudden unexpected death in epilepsy, usually occurs during/immediately after a seizure

Risk factors:

  • poor epileptic control
  • young age
  • generalised tonic-clonic seizures
  • learning disabilities
  • seizures during sleep
  • unwitnessed seizures
  • poor compliance
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