Treatment of epilepsy

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• Treatment of epilepsy

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• 1)GENERAL MEASURES
• 2)ANTICONVULSAT THERAPY

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1)General measures

• a- AVOIDANCE OF EPILEPTIC STIMULI
• b- PSYCHIC SUPPORT
• c- SAFETY MEASURES

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AVOIDANCE OF EPILEPTIC STIMULI

• 1- fever
• 2- medications
• 3-photic stimulation
• 4-fatigue
• 5-hyperventilation

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2)ANTICONVULSAT THERAPY

• GOAL OF THERAPY
• To achieve COMPLETE seizure control with a SINGLE
  drug taken once or twice daily WITHOUT side
  effects

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GENERAL RULES

• 1- MONOTHERAPY
• 2- GRADED FASHION
• 3- CHOICE DEPENDS ON TYPE OF SEIZURE

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• 4- NEVER STOP AED SUDDENLY
• 5- A MINIMUM OF 2 SEIZURE FREE YEARS ARE REQUIRED
  IN PATIENTS WITHOUT RISK FACTORS
• 6- WEANING TAKES 3-6 mon

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BEFORE START OF TREATMENT CONSIDER

• 1)) RISK OF RECURRENCE
• 100 with preexisting neurological disorder
• 94 with partial seizures
• 20-25 with low risk factors
• 2)) DESCRIPTION OF ILLNESS AND ITS
  CHARACTERISTICS TO THE PARENTS

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Risk factors for recurrence

• 1- Symptomatic cases
• 2- Prior febrile seizures
• 3- Clear EEG abnormalities
• 4- Seizure in sleep
• 5- Difficulty of 1st control
• 6- Seizure type(more with focal)

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Stepwise plan

• Step 1
• Start with small dose of one 1st line drug as
  shown
• Dose increment if seizure continues and side
  effects does not occur
• If necessary the maximum tolerated dose

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• Step 2
• if seizure continues despite the maximum
  tolerated dose review your diagnosis
• Step 3
• another 1st line drug is added while withdrawing
  the 1st

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• step 4
• increase 2nd drug now to the maximum tolerated
  dose
• step 5
• if seizure continues consider combination of 2
  1st line drugs
• step 6
• if still introduce a 2nd line drug

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• INITIAL INVESTIGATIONS
• 1)Diagnostic e.g. blood glucose , renal and liver
  functions , calcium level ,
• basic CBC
• 2)EEG
• 3)Brain imaging

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Monitoring

• - Detecting adverse effects ( at least CBC and
  ALT every 6 mon.)
• -Serum antiepileptic drug concentrations
• Use
• 1- Check compliance
• 2- monitor pharmacokinetic interaction
• 3- whether symptoms and signs are likely to be
  side effects

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ANTIEPILEPTIC DRUGS FOR SEIZURE CONTROL

• (1) PARTIAL SEIZURES
• 1ST CHOICE DRUGS
• CARBAMAZEPINE
• VALPROATE

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• 2nd CHOICE DRUGS
• VIGABATRINE
• PHENYTOIN
• LAMOTRIGINE
• CLOBAZAM
• GABAPENTIN
• ACETAZOLAMIDE
• PHENOBARBITONE

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• (2)GENERALIZED TONIC-CLONIC SEIZURES
• 1ST CHOICE DRUGS
• VALPROATE
• CARBAMAZEPINE

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• 2nd CHOICE DRUGS
• PHENYTOIN
• LAMOTRIGINE
• CLOBAZAM
• VIGABATRINE
• ACETAZOLAMIDE

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• (3) ABSENCE
• 1ST CHOICE DRUGS
• ETHOSUXIMIDE
• VALPROATE
• 2nd CHOICE DRUGS
• ACETAZOLAMIDE

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• (4) ATYPICAL ABSENCE / ATONIC / TONIC
• 1ST CHOICE DRUGS
• VALPROATE
• 2nd CHOICE DRUGS
• LAMOTRIGINE
• ACETAZOLAMIDE
• CLONAZEPAM

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• (5)MYOCLONIC
• 1ST CHOICE DRUGS
• VALPROATE
• 2nd CHOICE DRUGS
• PHENOBARBITONE
• ACETAZOLAMIDE
• CLONAZEPAM

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• INFANTILE SPASMS
• 1ST CHOICE DRUGS
• ACTH
• 2nd CHOICE DRUGS
• VIGABATRINE
• CLONAZEPAM

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Pharmacology of the drugs in common use

• Carbamazepine (Tegretol)
• DoseBegin 10mg/ kg/ 24 hr ,Increase to 20
  30mg/ kg/ 24hr tid
• Side Effects and Toxicity
• Dizziness, drowsiness, diplopia, liver
  dysfunction, anemia, neutropenia, SIADH, blood
  dyscrasias rare, hepatotoxic effects

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• Valproic acid (Depakene)
• DoseBegin 10mg/ kg/ 24hr
• Increase by 5 10mg/ kg/ wk
• Usual dose, 30 60mg/ kg/ 24hr tid or qid
• Side Effects and Toxicity
• Nausea, vomiting, anorexia, amenorrhea, sedation,
  tremor, weight gain, alopecia, hepatotoxicity

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• Clonazepam (Rivotril)
• Dose
• Begin 0.05mg/ kg/ 24hr
• Increase by 0.05mg/ kg/ wk
• Maximum 0.2mg/ kg/ 24?hr bid or tid
• Side effects
• Drowiness, irritability, agitation, behavioral
  abnormalities, depression, excessive salivation

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• Topiramate (Topimax)
• Dose
• 1-9mg/ kg/ 24/hr bid
• Side effects
• Fatigue, cognitive depression

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• Lamotrigine (Lamictal)
• Dose
• 1.5-3 mg / kg / day on 2 divided doses
• Side effects
• Rash, dizziness, ataxia, somolence, diplopia,
  headache, nausea, vomiting

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• Phenobarbital
• Dose
• 3-5mg/ kg/ 24hr bid
• Side effects
• Hyperactivity, irritability, short attention
  span, temper tantrums, altered sleep pattern,
  Stevens-Johnson syndrome, depression of cognitive
  function

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• Phenytoin
• Dose
• 3-9mg/ kg/ 24hr bid
• Side effects
• Hirsutism, gum hypertrophy, ataxia, skin rash,
  Stevens-Johnson sydrome, nystagmus, nausea,
  vomiting, drowsiness, coarsening facial features,
  blood dyscrasias

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Withdrawing antiepileptic drug

• Between 60 and 75 of children seizure free for
  more than 2 years on medication remain so on
  withdrawal
• Almost half of the relapses occur within 6 mon.
  of withdrawal

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• Risk is increased when
• 1) prior neurological insult
• 2) if the age gt12 years
• 3) multiple seizure types
• 4) abnormal EEG

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• Duration of tapering
• 1) Phenytoin and Na valproate over 1-2 weeks
• 2) Carbamazepine , barbiturates and
  Benzodiazepines over several weeks
• 3) If barbiturates and Benzodiazepines have been
  used for long period they
• are withdrawn over months.

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