Epilepsy Treatment Principles Flashcards
Goals of therapy for epilepsy include…
Achieving complete seizure control
Decrease seizure frequency, severity, and type
Reduce morbidity + mortality
Improve quality of life
Minimize AE’s
Epilepsy treatment usually involves…
Medications (60-70% attain seizure free status)
Surgery for refractory cases
Patients with acute seizures from metabolic, toxic, and infectious etiologies may require treatment with…
ASM in the short term, but these are generally not continued once the patient’s medical problem has been resolved
Long-term treatment is usually considered once…
A diagnosis of epilepsy is made
Avg. risk of recurrence is ~50% if patient has 1 unprovoked seizure, but 60-90% if patient meets epilepsy diagnosis
Recall epilepsy diagnosis of 2 unprovoked seizures OR 1 unprovoked seizure + high risk for recurrence
Start with monotherapy
Titrate slowly (usually 1/4-1/3 of initial dose and increase q1-2 weeks)
Titrating minimizes risk of dose-dependant side fx
Speed of ASM titration may differ based on…
Patient-sepcific factors
Elderly = slower titration
Frequent seizures = faster titration
If a patient has an inadequate response to initial therapy, (has seizures) we should…
Inquire about medication adherence
If at moderate dose (with few side fx), titrate up to maximum dose
If a patient continues to experience breakthrough seizures at their maximum tolerated dose, we could consider…
Initiating a different 1st line ASM as monotherapy (start new agent, then taper off old unless intolerable AE’s)
OR
Initiate combination therapy by adding a 2nd ASM
Possible benefits of monotherapy include…
Fewer idiosyncratic reactions
Increased probability of adherence
More cost-effective
Possible benfits of polytherapy include…
Fewer side effects with lower doses of 2 concomitant ASM’s
Unclear if efficacy is increased, but ~10% of patients will be well-controlled on 2 ASM’s
This is usually reserved for patients that have failed monotherapy with 2-3 drugs; would try an ASM with a different/complimentary MOA
Benefits of stopping ASM therapy may include…
Reducing polypharmacy, decrease AE’s and improving cognition (CNS depression)
Risk of stopping ASM therapy may include…
Risk of recurrent seizures; seizure control may be lost long-term
Factors that favour successful discontinuation of ASM’s include…
- Seizure-free period of 2-5 years for adults, 2 years for children
- Normal neurologic exam
- Normalized EEG with treatment
- Hx of single type of focal seizure or generalized tonic-clonic seizure
If withdrawing from ASM, we should taper…
SLOWLY and gradually, to prevent relapse seizures and status epilepticus
If on 1+ ASM, each one should be withdrawn separately
Non-pharmacologic therapies for seizures include…
Diet
Surgery
Vagus Nerve Stimulation
