Treatment of Epilepsy (Week 5--Degiorgio)

Question 1

When should we initiate treatment for epilepsy?

Answer 1

Definitely after 2 or more unprovoked seizures

Consider treatment after first seizure if abnormal MRI (cyst, tumor, etc) or EEG

Early treatment reduces risk of second seizure in first 2 years

Question 2

When should we stop treatment for epilepsy?

Answer 2

If seizure free for at least 1-2 years

Best candidates have normal MRI and EEG and excellent response to initial treatment

Question 3

What should we use as first line therapy for epilepsy?

Answer 3

Carbamazepine (however, has rash, preg class D, requires monitoring)

Levetiracetam (however, has insomnia, depression)

Question 4

Treatment for partial seizures

Answer 4

Lamotrigine better tolerated than carbamazepine

Lamotrigine and carbamazepine equivalent for long term efficacy

Both better than gabapentin

Answer: lamotrigine, carbamazepine, oxcarbazepine (maybe levetiracetam)

Question 5

Treatment for generalized epilepsy

Answer 5

Valproate is the best but must consider birth defects

(Valproate better than lamotrigine and topiramate)

Answer: valproate and lamotrigine

Question 6

Treatment for absence (petit mal) seizures

Answer 6

Ethosuximide or valproate better than lamotrigine

Ethosuximide less cognitive side effects

Answer: ethosuximide and valproate

Question 7

Drugs to avoid if you have a history of rash

Answer 7

Lamotrigine

Carbamazepine

Phenytoin

Question 8

Drugs to avoid if you want to get pregnant

Answer 8

Valproate

Carbamazepine

Phenytoin

(take lamotrigine or levetiracetam instead)

Question 9

Drugs to avoid if you have a history of behavior problems

Answer 9

Levetiracetam

Topiramate

Zonisamide

Lacosamide

Question 10

Drugs to try if you have a history of previous drug failures

Answer 10

Topiramate

Levetiracetam

Lacosamide

Question 11

Teratogenicity of AEDs

Answer 11

Fetal malformations in 6%

Higher risk with polytherapy

Highest risk with class D: phenytoin, valproate, phenobarbital, carbamazepine

Lower risk class C: lamotrigine, levetiracetam, gabapentin

Can prevent these birth defects by taking folic acid

Question 12

Sudden death in epilepsy

Answer 12

3-9/1,000

Highest risk for 18-40 yo and long duration of epilepsy; frequent grand mal seizures, on multiple AEDs

Etiology: hypoxia, cardiac arrhythmias

Prevention: nighttime supervision, listening device, control grand mal seizures

Question 13

How do we use DBS as treatment for epilepsy?

Answer 13

If drugs don’t work

Anterior thalamic DBS

Not yet FDA approved

Seizure frequency reduced by 66%

Question 14

Direct cortical stimulation

Answer 14

NeuroPace device

29% seizure reduction

Senses electrical activity then delivers a pulse and stops the seizure

Question 15

Vagus nerve stimulation

Answer 15

Right vagus projects to SA node

Left vagus projects to AV node

Question 16

Trigeminal nerve stimulation

Answer 16

3 divisions of trigeminal nerve

Brainstem: NTS, locus coeruleus, vagus nerve nuclei

Thalamus

Cortex

Question 17

Summary about epilepsy treatment

Answer 17

Use valproate and lamotrigine for generalized seizures

Use ethosuximide and valproate for absence seizures in children

Use lamotrigine, carbamazepine, oxcarbazepine and others for partial seizures

Use topiramate, levetiracetam and lacosamide for drug resistant epilepsy

Avoid valproate, carbamazepine, phenytoin in pregnancy