Epilepsy treatment

1. Epilepsy and Seizures
Treatment & Management
Dr. Md Rashedul Islam
FCPS, MRCP(UK)
Registrar, Neurology, BIRDEM

2. 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.

3. 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

4. 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

5. 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

6. 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

8. Adverse Effects of Commonly Used
Antiepileptic Drugs
Drug Principal use Adverse effects
Valproic acid Tonic-clonic
Absence
Atypical
absence
Myoclonic
Focal-onset
Atonic
Ataxia
Sedation
Tremor
Hepatotoxicity
Thrombocytopenia
Gastrointestinal irritation
Weight gain
Transient alopecia
Hyperammonemia

9. Adverse Effects of Commonly Used
Antiepileptic Drugs
Drug Principal use Adverse effects
Carbamazepine UsesTonic-clonic
Focal-onset
Ataxia
Dizziness
Diplopia
Vertigo
Stevens johnson syndrome
Aplastic anemia
Leukopenia
Gastrointestinal irritation
Hepatotoxicity
Hyponatremia

10. Adverse Effects of Commonly Used
Antiepileptic Drugs
Drug Principal use Adverse effects
Levetiracetam Focal-onset
GTCS
Sedation
Fatigue
Incoordination
Mood changes
Anemia
Leukopenia

11. Adverse Effects of Commonly Used
Antiepileptic Drugs
Drug Principal use Adverse effects
Oxcarbazepine Focal-onset
Tonic-clonic
Fatigue
Ataxia
Dizziness
Diplopia
Vertigo
Headache
Aplastic anemia
Leukopenia
Gastrointestinal irritation
Hepatotoxicity
Hyponatremia
Hypersensitivity

12. Nonpharmacologic Management
 Ketogenic diet and modified Atkins diet
 Vagal nerve stimulation
 Implantable neurostimulator

13. 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

14. Anticonvulsants in Specific Patient
Populations
Women 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

15. 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

16. 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

17. 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.

19. 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

20. 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.

21. 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

22. 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

23. THANK YOU