Epilepsy

Question 1

How many people in the uk suffer with epilepsy?After a first seizure, what is the chance of having a second?After a second seizure, what is the chance of having more?How many percentage of people on anti epileptics become seizure free?

Answer 1

40,000 people in the uk have epilepsy.The chance of having a second seizure is 50% in the next 2 years. The chance of having a third seizure after having 2 is 70%.70-80% on anti epileptics become seizure free.

Question 2

If you suspect a first seizure, how quickly should the patient be seen by a specialist?

Answer 2

Within 2 weeks (excluding febrile convulsions, unless there is an additional reason, e.g., source not identified).

Question 3

Should GP start Rx for a first seizure? If non-epileptic attack disorder/pseuodoepilepsy is suspected, who should they be referred to?

Answer 3

GP should not start anti epileptic Rx unless advised to by a specialist. If pseuodoepilepsy suspected, then refer to a psychiatrist or psychologist for further evaluation.

Question 4

What investigations for a new patient with epilepsy?

Answer 4

Bloods (U&E, glucose, calcium.ECG.EEG.MRI (or other neuro imaging, but MRI is gold standard).In children/young people neuropsychological assessment might be indicated, to make sure no learning difficulties or cognitive impairment.

Question 5

At diagnosis, and as often as needed, what info should patients with epilepsy receive?

Answer 5

-Rx options, including medication, s/e’s and prognosis.-Risk management, first aid and safety at home/work/school.-Issues relating to home life/hobbies/social/sleep deprivation/drugs and alcohol.-Importance of disclosing epilepsy to school/work.-Psychological issues, benefits, insurance issues.-Road safety and driving.-SUDEP.-Status epilepticus.-Support groups.

Question 6

What are the general principles of drug initiation in epilepsy?

Answer 6

-Should be initiated by a specialist, not by GP.-After a single seizure, medication may or may not be started, especially if there is doubt as to the diagnosis. But if diagnosis is confirmed - e.g., epileptiform activity on EEG - it is almost always started.-Almost always started after a second seizure.-Consistent use of same preparation is preferable.-If initial mono therapy not tolerated, switch to a different mono therapy.

Question 7

When should epilepsy be treated with more than one agent?

Answer 7

Only if mono therapy with a variety of agents has failed. If treatment with more than one agent is not effective –> switch back to best tolerated mono therapy.

Question 8

In what group should especial care be taken when using valproate?

Answer 8

Women of childbearing age, as there is a risk of congenital malformations and neurodevelopment effects, esp at higher doses.

Question 9

In what groups should carbamazepine not be initiated without carrying out a specific test? What test? Why?

Answer 9

People of Han Chinese origin. Should test for HLA-B1502 first (increased risk of Stevens-Johnspon syndrome).

Question 10

When should blood levels of anti epileptics be measured?

Answer 10

Rarely! Only do if:-Suspected toxicity-Suspected non-adherance.-Specific clinical situation (e.g., organ failure, pregnancy).-Change in bioavailability (e.g., new drug started).

Question 11

When might withdrawing a drug be considered?

Answer 11

-Only under specialist supervision.-After seizure free for 2 years.Done slowly, over 2-3/12.

Question 12

When should emergency initiation of treatment for a seizure be carried out?

Answer 12

-If lasts longer than 5 minutes.-If more than 3 in 1 hr.

Question 13

What is emergency drug Rx for a seizure?

Answer 13

-Adults - buccal midazolam (10mg); rectal diazepam (10-20mg) is alternative. (Repeat after 15min if unsuccessful).-Children - buccal midazolam, 0.mg/kg, maximum of 10mg. (Repeat after 10min if no effect). Buccal midazolam is now licensed for children, “buccolam”.

Question 14

When attending someone with a seizure in the community, when should an ambulance be called?

Answer 14

1) if this is a first seizure.2) if seizure is continuing 5 min AFTER medicine is given.3) concerns about ABC.

Question 15

When should emergency seizure-aborting drugs be prescribed for, e.g., patients to have at school?

Answer 15

Not for everyone with epilepsy!Only if a patient has had previous episodes of prolonged seizures/serial convolutions.

Question 16

What about epilepsy in pregnancy?

Answer 16

In pregnancy early specialist referral is indicated (ideally pre-conception specialist advice too!).Seizure frequency usually doesn’t change in pregnancy or immediately after delivery.The risk of seizure during labour is low (1–4%) but this is sufficiently high to recommended delivery in an obstetric led unit.Vitamin K is indicated for the baby on delivery (1mg im).Epilepsy is rarely passed on to the chid unless there is a family history. In these cases genetic counselling may be indicated.Most women should be encouraged to breast feed, even when on drug therapy.The risk to the infant from a maternal seizure is low.

Question 17

Women and girls with epilepsy -what issues?

Answer 17

Careful counselling about contraception, conception, pregnancy, breast feeding are required.Be aware of interactions with contraception (advice from the Faculty of Sexual and Reproductive Health is outlined below)There are concerns about the impact of epilepsy drugs on the fetus (congenital malformations and neurodevelopmental problems).Offer all women of child-bearing age on anti-epileptics 5mg of folic acid daily.

Question 18

When should patients with epilepsy be reviewed?

Answer 18

Every year, both by the specialist and by the GP.This is to discuss compliance, s/e’s, and control.If seizures are not controlled in secondary care, referral to a tertiary centre is recommended.

Question 19

What is SUDEP? How to reduce the risk?

Answer 19

Sudden Unexplained Death in Epilepsy.Risk is reduced by optimising seizure control.Being aware of potential consequences of nocturnal seizures.

Question 20

What are the statistics regarding SUDEP?

Answer 20

Absolute risk is 1/1000, raising to 2-5/1000 in those referred to tertiary centres.In adults, 33% thought to be avoidable, rising to 55% in children.Biggest r/f is poor seizure control.Failure to collect scripts for anti-epileptics has been identified as a warning sign.People who have SUDEP are usually found dead in bed with evidence of a recent seizure.Epilepsy Bereaved is special charity that supports people who have lost loved ones due to SUDEP.

Question 21

Many anti-epileptics are enzyme inducers - what contraceptives do these have an impact on?

Answer 21

COC, POP, and progesterone implants.They do NOT effect IUS or depot medroxyprogesterone (though they nave have an impact on the norethistrone implant - the 8w injection).

Question 22

Which antieplieptics are strong enzyme inducers?

Answer 22

CarbamazapineEslicarbazepineOxcarbazepinePhenytoinPhenobarbitolPrimidone

Question 23

Which anti epileptics are weak enzyme inducers?

Answer 23

Topiramate, rufinamide

Question 24

Which anti-epileptics have no significant effect as enzyme inducers?

Answer 24

Benzos (obviously!)EthosuximideValproateLamotrigine GabapentinePregabalineLacosamidLevetiracetamTiagabineVigabatrinZonisamide

Question 25

Tell me about lamotrigine and contraception?

Answer 25

Although lamotrigine is not a strong enzyme inducer, COCP does reduce lamotrigine levels. The POP does not; and interestingly, when the combination of valproate and lamotrigine are in use, initiating the COC does NOT reduce lamotrigine levels. Weird, eh?

Question 26

Which anti-epileptics reduce bone mineral density?

Answer 26

CarbamazepinePhenytoinValproatePrimidone

Question 27

What emergency contraception should be used in those taking anti-epileptics?

Answer 27

IUD is the preferred choice.Ulipristal should NOT be used.Those who prefer taking levonorgestrel should take a double dose (i.e., 3g) as soon as possible within the first 72hrs.

Question 28

Driving - type 1 vehicles and epilepsy - what are the rules?

Answer 28

First unprovoked seizure - can drive 6 months after the seizure (though this may be increased if there is a high risk of recurrence, as determined by Ix).Confirmed epilepsy - if seizure occurred while awake, 12/12 ban. If someone continues to have seizures, but only at night, then they can drive after 3 years, but ONLY if they do not have seizures while awake (then the 12/12 ban applies.Withdrawing medication - advise not to drive while the medication is being withdrawn and for 6/12 afterwards.

Question 29

Driving - type 2 vehicles and epilepsy - what are the rules?

Answer 29

First unprovoked seizure - can drive if seizure free off all meds for 5 years.Confirmed epilepsy - can drive again when seizure free off all medication for 10 years.Withdrawing medication - not applicable.