EPILEPSY

Diagnosis

• Refer to specialist ? < 28 days• 50% of referred pts don’t have epilepsy• 20% of pts on epilepsy medication have

been misdiagnosed• Diagnosis may have profound

psychological social and financial implications

• Inability to drive, unemployment, low self esteem, discrimination

History

• Eye witness account• Dates and times of seizures• What where they doing• Any mood changes – extreme

excitement, anxiety, anger.• Any loss of consciousness or confusion• Skin colour changes – pale, flushed,

blue.

History

• Alteration of breathing – noisy or difficult

• Did body stiffen, jerk or twist• Incontinence• Bite tongue or cheek• How long was seizure• How where they afterwards – tired,

confused.• How long till normal

Examination

• Blood pressure

• Pulse, heart sounds, carotid bruits.

• Cranial nerves

• Fundi

• Tone power coordiantion

Investigations

• Fasting blood sugar

• Fbc

• U&E

• LFT’s

• TFT’s

Advice

• Bathing

• Swimming

• Driving most stop till sees specialist

• Other high risk activities

• Document discussion in notes

• Recurrence risk is 30% over next 6/12

Goals of therapy

• Complete freedom from seizures

• No side effects of medication

• No impact on quality of life

• Least medication necessary

Epilepsy

• Prevalence 4-10 per 1000 population

• 50% female

• Life long condition

New contract

• Compile a register of patients with epilepsy receiving drug treatment

• Review them annually• Record seizure frequency and date

of last seizure• Aim to achieve seizure freedom in

705 of patients.

Special issues for Women

• Fertility• Contraception• Preconceptual counselling• Management of pregnancy• Risk to developing foetus• Menopause• Osteoporosis risk factors

Adolescence

• Ensure handover from paediatric

service to adult service occurs

• Effect of menstrual cycle on seizures –

clustering round menstruation

• Contraception

Medication

• Drugs licensed for monotherapy

• Carbamazepine

• Lamotrigine

• Oxycarbazepine

• Sodium valproate

• Topiramate

Medication

• Drugs should be started by specialist

• May change as pts need change

• If first drug fails, then second drug tried as monotherapy.

• Check drug levels for adherence and toxicity only not for dosing except phenytoin

Medication

• Treat pt not drug level

• If drug level low but seizures controlled

don’t later dose

• If drug level normal but pt has toxicity

then decrease dose

• Monitor LFT’s in first 6/12

Contraception

• Non enzyme inducing AED’s have no

effect on hormonal contraception

• Gabapentin

• Lamotrigine

• Levetiracetam

• Sodium valproate

Contraeption

• Hepatic enzyme inducing AED’s• Carbamazepine• Ethosuxamide• ? Oxycarbazepine• Phenobarbitone• Phenytoin• Primidone• ? Topiramate

Contraception

• Women on enzyme inducing AED’s should use• Higher dose COC 50 mcg ostradiol or

mestranol = norinyl-1or use 2x30mcg coc = 60mcg if break trough bleeding occurs with norinyl

• Depot provera reduce interval to 10/52

• POP’s and implants have higher failure rates with AED’s

Contraception

• Even with high dose coc pts still at risk of pregnancy

Reduce pill free interval to 4 days

• Tricycle

• Reduce pill free interval to 4 days

• Use barrier contraception as well

• Despite these 3 measures women on enzyme inducing

AED’s and coc are considered to be at increase risk of

pregnancy

Contraception

• COC should not be first choice for pts on AED’s

• Failure rate is 7%

• Still lower than barrier methods = 15-20%

Emergency Contraception

• Use normally in pts on non enzyme

inducing AED’s

• On enzyme inducing AED’s

• Higher dose levonorgestrel 2pills stat

followed by 1 pill 12 hours later

• IUD is more reliable

Preconceptual counselling

• 1 in 200 women in ANC are on AED’s

• Seizures may increase in frequency or change in type in pregnancy

• Seizures during pregnancy and exposure to AED’s in utero influence the poorer outcomes seen in babies born to mothers with epilespy

Preconceptual advice

• AED’s increase by 2-3x major

abnormality rate

• Background rate 1-2%

• Pts on AED’s have 3-9%

Preconceptual advice

• Major abnormalities related to AED’s• Cleft palate

• Spina bifida

• Heart Defects

• Minor abnoramlities• Dysmorphic features

• Digital abnormalities

Preconceptual advice

• Also concerns re

• Growth retardation

• Learning disabilities

• Important to discuss issues about pregnancy well before patient wants to conceive

• Should be rasied frequently and documented when being reviewed so pt well aware

Preconceptual advice

• Aims• To raise awaresness among women that the

best outcome inpregnancy may be secured if the pregnancy is planned.

• Optimize medication ?change drugs• Improve seizure control• Decrease risk of presnting in pregnancy on

AED with poor abnormality profile

Preconceptual advice

• Women with epelepsy considering pregancy should be referred to specialist for review of management

• If seizure free for 2-3 years consider withdrawing AED’s

• Risk to foetus from sudden withdrawal or non adherence to AED’s is greater than continued exposure to AED’s

Preconceptual advice

• Sudden stooping of AED’s may cause

• SUDEP

• Status epilepticus

Teratogenicty

• Polytherapy risk – 15-20%• Monotherapy - 4-6%• Sodium valproate – 5.9%• Carbamazepine – 2.3%• Lamotrigine – 2.1%• Take folic acid 5mg to prevent neural

tube defects till 3/12• 3% risk of passing epilepsy to child

Management in pregnancy

• Refer to specialist ANC clinic• Optimize seizure control during

pregnancy• Importance of adhering to medication• High resolution ultrasound for

malformations• Increased risk seizures postpartum

Management in pregnancy

• High dose folic acid till 3/12

• Pts on enzynme inducing AED’s need

oral vit K 20mg/day from 36/52 until

delivery

Safety issues for baby

• If frequent seizures

• Feed baby sittng on floor supported

by cushions

• Change baby at floor level

• Don’t bathe baby by herself

• Safety gates and play pens

DVLA

• Planned withdrawal

• Don’t drive duirng withdraal or for

6/12 afterwards

• Changing drugs

• Few weeks off driving for observation

during change over

DVLA

• If patient has seizure during or

after withdrawal

• No driving till 1 year seizure free

• Or 3 years only nocturnal seizures