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Diagnosis
• Refer to specialist ? < 28 days• 50% of referred pts don’t have epilepsy• 20% of pts on epilepsy medication have
been misdiagnosed• Diagnosis may have profound
psychological social and financial implications
• Inability to drive, unemployment, low self esteem, discrimination
History
• Eye witness account• Dates and times of seizures• What where they doing• Any mood changes – extreme
excitement, anxiety, anger.• Any loss of consciousness or confusion• Skin colour changes – pale, flushed,
blue.
History
• Alteration of breathing – noisy or difficult
• Did body stiffen, jerk or twist• Incontinence• Bite tongue or cheek• How long was seizure• How where they afterwards – tired,
confused.• How long till normal
Examination
• Blood pressure
• Pulse, heart sounds, carotid bruits.
• Cranial nerves
• Fundi
• Tone power coordiantion
Advice
• Bathing
• Swimming
• Driving most stop till sees specialist
• Other high risk activities
• Document discussion in notes
• Recurrence risk is 30% over next 6/12
Goals of therapy
• Complete freedom from seizures
• No side effects of medication
• No impact on quality of life
• Least medication necessary
New contract
• Compile a register of patients with epilepsy receiving drug treatment
• Review them annually• Record seizure frequency and date
of last seizure• Aim to achieve seizure freedom in
705 of patients.
Special issues for Women
• Fertility• Contraception• Preconceptual counselling• Management of pregnancy• Risk to developing foetus• Menopause• Osteoporosis risk factors
Adolescence
• Ensure handover from paediatric
service to adult service occurs
• Effect of menstrual cycle on seizures –
clustering round menstruation
• Contraception
Medication
• Drugs licensed for monotherapy
• Carbamazepine
• Lamotrigine
• Oxycarbazepine
• Sodium valproate
• Topiramate
Medication
• Drugs should be started by specialist
• May change as pts need change
• If first drug fails, then second drug tried as monotherapy.
• Check drug levels for adherence and toxicity only not for dosing except phenytoin
Medication
• Treat pt not drug level
• If drug level low but seizures controlled
don’t later dose
• If drug level normal but pt has toxicity
then decrease dose
• Monitor LFT’s in first 6/12
Contraception
• Non enzyme inducing AED’s have no
effect on hormonal contraception
• Gabapentin
• Lamotrigine
• Levetiracetam
• Sodium valproate
Contraeption
• Hepatic enzyme inducing AED’s• Carbamazepine• Ethosuxamide• ? Oxycarbazepine• Phenobarbitone• Phenytoin• Primidone• ? Topiramate
Contraception
• Women on enzyme inducing AED’s should use• Higher dose COC 50 mcg ostradiol or
mestranol = norinyl-1or use 2x30mcg coc = 60mcg if break trough bleeding occurs with norinyl
• Depot provera reduce interval to 10/52
• POP’s and implants have higher failure rates with AED’s
Contraception
• Even with high dose coc pts still at risk of pregnancy
Reduce pill free interval to 4 days
• Tricycle
• Reduce pill free interval to 4 days
• Use barrier contraception as well
• Despite these 3 measures women on enzyme inducing
AED’s and coc are considered to be at increase risk of
pregnancy
Contraception
• COC should not be first choice for pts on AED’s
• Failure rate is 7%
• Still lower than barrier methods = 15-20%
Emergency Contraception
• Use normally in pts on non enzyme
inducing AED’s
• On enzyme inducing AED’s
• Higher dose levonorgestrel 2pills stat
followed by 1 pill 12 hours later
• IUD is more reliable
Preconceptual counselling
• 1 in 200 women in ANC are on AED’s
• Seizures may increase in frequency or change in type in pregnancy
• Seizures during pregnancy and exposure to AED’s in utero influence the poorer outcomes seen in babies born to mothers with epilespy
Preconceptual advice
• AED’s increase by 2-3x major
abnormality rate
• Background rate 1-2%
• Pts on AED’s have 3-9%
Preconceptual advice
• Major abnormalities related to AED’s• Cleft palate
• Spina bifida
• Heart Defects
• Minor abnoramlities• Dysmorphic features
• Digital abnormalities
Preconceptual advice
• Also concerns re
• Growth retardation
• Learning disabilities
• Important to discuss issues about pregnancy well before patient wants to conceive
• Should be rasied frequently and documented when being reviewed so pt well aware
Preconceptual advice
• Aims• To raise awaresness among women that the
best outcome inpregnancy may be secured if the pregnancy is planned.
• Optimize medication ?change drugs• Improve seizure control• Decrease risk of presnting in pregnancy on
AED with poor abnormality profile
Preconceptual advice
• Women with epelepsy considering pregancy should be referred to specialist for review of management
• If seizure free for 2-3 years consider withdrawing AED’s
• Risk to foetus from sudden withdrawal or non adherence to AED’s is greater than continued exposure to AED’s
Teratogenicty
• Polytherapy risk – 15-20%• Monotherapy - 4-6%• Sodium valproate – 5.9%• Carbamazepine – 2.3%• Lamotrigine – 2.1%• Take folic acid 5mg to prevent neural
tube defects till 3/12• 3% risk of passing epilepsy to child
Management in pregnancy
• Refer to specialist ANC clinic• Optimize seizure control during
pregnancy• Importance of adhering to medication• High resolution ultrasound for
malformations• Increased risk seizures postpartum
Management in pregnancy
• High dose folic acid till 3/12
• Pts on enzynme inducing AED’s need
oral vit K 20mg/day from 36/52 until
delivery
Safety issues for baby
• If frequent seizures
• Feed baby sittng on floor supported
by cushions
• Change baby at floor level
• Don’t bathe baby by herself
• Safety gates and play pens
DVLA
• Planned withdrawal
• Don’t drive duirng withdraal or for
6/12 afterwards
• Changing drugs
• Few weeks off driving for observation
during change over
DVLA
• If patient has seizure during or
after withdrawal
• No driving till 1 year seizure free
• Or 3 years only nocturnal seizures