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EPILEPSY

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.

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EPILEPSY

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  1. EPILEPSY

  2. 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

  3. 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.

  4. 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

  5. Examination • Blood pressure • Pulse, heart sounds, carotid bruits. • Cranial nerves • Fundi • Tone power coordiantion

  6. Investigations • Fasting blood sugar • Fbc • U&E • LFT’s • TFT’s

  7. 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

  8. Goals of therapy • Complete freedom from seizures • No side effects of medication • No impact on quality of life • Least medication necessary

  9. Epilepsy • Prevalence 4-10 per 1000 population • 50% female • Life long condition

  10. 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.

  11. Special issues for Women • Fertility • Contraception • Preconceptual counselling • Management of pregnancy • Risk to developing foetus • Menopause • Osteoporosis risk factors

  12. Adolescence • Ensure handover from paediatric service to adult service occurs • Effect of menstrual cycle on seizures – clustering round menstruation • Contraception

  13. Medication • Drugs licensed for monotherapy • Carbamazepine • Lamotrigine • Oxycarbazepine • Sodium valproate • Topiramate

  14. 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

  15. 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

  16. Contraception • Non enzyme inducing AED’s have no effect on hormonal contraception • Gabapentin • Lamotrigine • Levetiracetam • Sodium valproate

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

  18. 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

  19. 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

  20. Contraception • COC should not be first choice for pts on AED’s • Failure rate is 7% • Still lower than barrier methods = 15-20%

  21. 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

  22. 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

  23. Preconceptual advice • AED’s increase by 2-3x major abnormality rate • Background rate 1-2% • Pts on AED’s have 3-9%

  24. Preconceptual advice • Major abnormalities related to AED’s • Cleft palate • Spina bifida • Heart Defects • Minor abnoramlities • Dysmorphic features • Digital abnormalities

  25. 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

  26. 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

  27. 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

  28. Preconceptual advice • Sudden stooping of AED’s may cause • SUDEP • Status epilepticus

  29. 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

  30. 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

  31. 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

  32. 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

  33. DVLA • Planned withdrawal • Don’t drive duirng withdraal or for 6/12 afterwards • Changing drugs • Few weeks off driving for observation during change over

  34. DVLA • If patient has seizure during or after withdrawal • No driving till 1 year seizure free • Or 3 years only nocturnal seizures

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