PHARMACOLOGICAL MANAGEMENT OF EPILEPSY

EPILEPSY VERSUS SEIZURE

A seizure is symptom caused by abnormal electrical discharges in the brain

Epilepsy is a disorder characterized by recurring seizures

A seizure is a symptom of epilepsy

EPILEPSY-CLASSIFICATIONFocal seizures account for 80% of adult epilepsies

Generalized seizures

Unclassified seizures

INCIDENCE OF EPILEPSY BY AGE

CAUSES OF EPILEPSY

POST-TRAUMATIC EPILEPSYEpilepsy arising as a result of head trauma

Head trauma may be subtle or severe

Extent & location of injury may increase likelihood of developing seizures 2 types of seizures -early/acute & delayed onset

Early treatment with anti-epileptic drugs (AEDs) may not affect the development of seizures later on

MORTALITYRisk of death higher in people with epilepsy

Mortality rate associated with seizures lasting > 30 minutes may be as high as 19%

Vast majority of deaths occur in people with seizure in the context of an acute brain insult, hypoxia, trauma, etc.

Sudden Death in Epilepsy (SUDEP)

A Spectrum of SeverityUncomplicated epilepsySeizures refractory to treatmentIncrease risk of SUDEP

Case 01A 24 year old male with idiopathic generalized epilepsy, who has been defaulted treatment for 2 months, admitted with recurrent GTC seizures without regaining consciousness in between.

IV Benzodiazepines

Lorazepam4-8mgMaximum effect in 2 minLasting for 4-6hourDiazepam5-30mgAct early(10-20sec)Lasting only for 2 hourMidazolam2.5-10mgAct in < 1minCan be used as infusion

ComplicationsOver sedationHypotensionRespiratory depressionTolerance

IV Phenytoin

Dose20mg/kg

Case 2A, 30 year male with post-traumatic epilepsy presented with unsteady gait for one week and double vision for 3 days. He was on phenytoin and phenobarbitone since the time of RTA and his medication changed to carbamazepine 200mg tds recently.

Carbamazepine

Dose800 1200mg daily

Side effectsAtaxia/diplopiaSkin rash

Other usesTrigeminal neuralgiaBipolar disorderNeuropathic pain

Phenytoin

Dose150 400mg daily

Side effectsGum hypertrophyDose related toxicity

Other uses?Anti-arrhythmic

Phenobarbitone

Dose30 120 mg daily

Side effectsDepressionWithdrawal seizures

Other usesPreoperative sedation

Case 3A, 26 year old newly married female with Juvenile Myoclonic epilepsy who has been on Sodium valproate is being evaluated in the routine clinic.

Sodium valproate

Dose600mg - 3g

Side effectsHepatotoxicityHair loss

Other usesManiaMigraine

Levetiracetam

Dose1000mg 3g

Side effectsSedationBehavioral disturbances

Other usesMyoclonus

A, 64 year old male with post stroke epilepsy has developed painful loss of vision of the right eye. His medications include Topiramate, Lamotrigine and Oxcarbazepine.

Topiramate

Dose50 400mg daily

Side effectsWeight lossImpaired cognition

Other usesMigraine Diabetic neuropathy

Oxcarbazepine

Dose600-1200mg daily

Side effectsSkin rashvertigo

Other usesNeuropathic painBipolar disorder

Lamotrigine

Dose100 300mg daily

Side effectsSkin rashNausea

Other usesBipolar disorderTrigeminal neuralgia

SUMMARY Definition of seizure

Definition of epilepsy

Causes and burden of epilepsy

Management of status epilepticus

Pharmacology of antiepileptics

**Epilepsy affects individuals to varying degrees. The spectrum of disability it creates is broad, ranging from a very limited effect on the individual to a devastating impact on all aspects of life. For a majority (perhaps as high as 80%) of people with epilepsy, seizures can be substantially reduced or completely controlled and may have limited impact on quality of life although memory and attention may pose additional challenges. For the remaining 20%, epilepsy is truly disabling, marked by frequent seizures, and other impairments, and a dramatically reduced quality of life.

Children whose seizures are not well controlled often experience social, emotional, and academic problems that compromise various stages of development. These problems may extend into adult life, where the same issues become barriers to employment and independence.

Question: What are some of the social issues that you think are important to people with epilepsy?