Neurological Management Of Epilepsy

Question 1

What is sparse coding?

Answer 1

Few neurons are needed to fire together to drive particular tasks

Question 2

How does epilepsy differ from sparse coding?

Answer 2

Larger populations of neurons fire at once and disrupt that area’s firing

Question 3

What’s the prevalence of epilepsy?

Answer 3

0.5-1%

Question 4

What factors increase seizure likelihood in epilepsy?

Answer 4

Lack of sleep
Alcohol intake
Stress/excitement

Question 5

Why is a consistent supply of a particular manufacturer’s medication recommended?

Answer 5

A patient may not trust a different looking medication which reduces concordance with medication

Question 6

What happens if events continue despite an optimal dose of first line therapy?

Answer 6

Re-evaluate diagnosis of epilepsy
Treat with a different ASM
Don’t combine therapies unless several different monotherapies have failed

Question 7

How many antiepileptic drugs are available in the UK?

Answer 7

29

Question 8

What are the limitations of RCTs?

Answer 8

Don’t help with clinical decisions
Compared to placebo
Trialled on treatment resistant epilepsy
Trialled as an add on to current therapy
(These conditions are rarely seen in practice)

Question 9

What are the limitations of comparative trials?

Answer 9

Often in new-onset treatment-naive epilepsy

Question 10

What is the most cited epilepsy publication ever?

Answer 10

Kwan and Brodie, 2000
525 patients
63% seizure free for 12 months+

47% of naive were seizure free with the first monotherapy
14% with second monotherapy
3% with 3rd try combination therapy (20% of refractory group)

Question 11

What did the SANAD trial (Marson et al 2007) show?

Answer 11

Valproate was better in generalised epilepsy
Lamotrigine was better in focal epilepsy

Question 12

What were the findings from three Nevitt meta analysis?

Answer 12

Valproate better in generalised seizures
Levetiracetam then Lamotrigine for focal

Question 13

What are the most effective drugs for halting seizures, delaying seizures or stopping status epilepticus?

Answer 13

Phenobarbital
Phenytoin

Question 14

Why would Levetiracetam be used first for focal onset seizures?

Answer 14

Well tolerated
No interactions
Had the slowest time to drop out in meta

Question 15

What are purported effects of sodium valproate?

Answer 15

Foetal malformation
Metabolic syndrome
Weight gain
Hypertension
Diabetes

Question 16

What is ethosuximide used for?

Answer 16

Absence seizures

Question 17

What is rational polytherapy?

Answer 17

Combining drugs that have different mechanisms of action - there is some anecdotal evidence but no trial evidence

Question 18

When would you do a blood test on epilepsy patient?

Answer 18

Suspicion of non adherence
If someone comes to A&R having seizures
Suspected toxicity
Organ failure
Organ transplant
Adjustment of phenytoin

Question 19

What were the seizure free rates for patients seizure free on drug treatment for 2+ years?

Answer 19

2 year seizure free rates:
78% of those continuing treatment
59% of those who stopped treatment

Question 20

What benzodiazepine is widely used for seizure clusters or prolonged seizures?

Answer 20

Oral clobazam

Question 21

Which medications work on GABA pathways?

Answer 21

Retigabine
Gabapentin
Pregabalin
Tiagabine
Benzodiazepines
Barbiturates

Question 22

Which medications work on glutamate pathways (inhibiting them)?

Answer 22

Levetiracetam (SV2A)
Phenytoin (VGSC)
Carbamazepine (VGSC)
Lamotrigine (VGSC)
Ethosuximide (Calcium channels and AMPA)

Question 23

What factors may impact treatment choice?

Answer 23

Child bearing
Interactions
Concordance
Weight issues

Question 24

What is the pregnancy prevention programme?

Answer 24

Women must commit to using barrier and internal contraceptive or to become permanently infertile

Question 25

What register helped find the teratogenicity of sodium valproate?

Answer 25

UK Epilepsy and Pregnancy Register

Question 26

When would someone be moved into tertiary care (NICE)

Answer 26

Children under 2
Uncontrolled epilepsy (2 years+, 2 failed meds)
Diagnostic doubt about nature of seizures
Psychological/psychiatric comorbidity
Structural lesion
Unacceptable side effects from medication

Question 27

What does NICE recommend about communication between patients and HCPs?

Answer 27

Endure there is an accessible point of contact with specialist services

Comprehensive care plan must be agreed

Lifestyle and medical issues addressed

Epilepsy specialist nurses should be an integral part of the network of care