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1 Pitfalls in Management of Epilepsy .. E-mail address: [email protected] http://epilepsy.kku.ac.th How we learn ? • 10% of what we read • 30% of what we see/heard • 50% of what we do • 70% of what we do,see and read Pitfalls Clinical System , (SE) : / (21 min/1-5 min) 1/3
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Page 1: How we learn in Management.pdf · 2009-02-12 · Dilantin (100) 1x3 Phenobarb gr I 2x2 Depakine (200) 2x3 ˜ ˆ˜. ˘ ...

1

Pitfalls in Management of Epilepsy ��.��.�������� �� !���"#

�#$#%�&#'�(�#�%��!# )#*%�&#+#!,��#�-�.

�/,"��0�1#%�2�!3�*/�&�� 3�4�!#5#/�� �*�����.

*6(7��!�#�-�. �8#%��!#/�!$+�7�"�

E-mail address: [email protected]

http://epilepsy.kku.ac.th

How we learn ?

• 10% of what we read

• 30% of what we see/heard

• 50% of what we do

• 70% of what we do,see and read

Pitfalls Clinical System

• �#�%���2C�! • *%#��DE, ����*-�

• �#�-�%2�#48E+4'G�5�-��#� • �#�H8E5���#�

• �#�H&E!#���&�� • *%#���IJ#���+�#�K�E��5!#• )#%(/�&��%��L-� (SE)

�#�%���2C�! : 'PQ8#

�'�(%�-�

�RDE�8S��8-,�#�6.

��%/#� IH&E��5RDE'T%!/�#! (21 min/1-5 min)

1/3 ���������� ������������� ������������������

Page 2: How we learn in Management.pdf · 2009-02-12 · Dilantin (100) 1x3 Phenobarb gr I 2x2 Depakine (200) 2x3 ˜ ˆ˜. ˘ ...

2

�#�%���2C�!: 7�%�#4

�H8E*%#���H2��5�#!/(�+ !�$+4'�(%�-�

�5���0� VDO

�[��'�(%�-��#43������.

��D VDO �#�&��&���-"#4, +\I�]

Tics Truncal myoclonus

HOME VDO

E#K�"��I�H2 +!"#���I4%���2C�!%"#�'_�3�*/�&��

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3

-�%+!"#4RDE'T%!

�8Q�4+#!, 28 'a +#& ��!#5#/

�� +#�#���(-,�$+4$#�(8%"#4�+�8/�5

�EEG �4��!%"#2(�'_� epileptic activity

�CT-brain: '�-�

���5!# sodium valproate: � $0g�

-�%+!"#4RDE'T%!

�3 ��\+�-"+�# ���������

���4%/��\I+4 teratogenic effect

�2(�J#+!"#4K�� ?

Teratogenic effect Teratogenic effect

Page 4: How we learn in Management.pdf · 2009-02-12 · Dilantin (100) 1x3 Phenobarb gr I 2x2 Depakine (200) 2x3 ˜ ˆ˜. ˘ ...

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Restless leg syndrome

�#�-�%2�#48E+4'G�5�-��#�

�EEG

�Imaging: CT, MRI-brain

�Blood chemistry : metabolic causes

�Therapeutic drug monitoring

������� ! ��""#����� : �%&'�

�K�"� 3�4�!#5#/�"4-�%2

�K�"� RDE7'�R/

�*%#�K%7/(*%#�2J#��#($+4�#�-�%2

�K�"� 45'�(�#6

�#�-�%2*/\I�Kmmn#��+4 : 7�%�#47�EK$

�K�"�"4-�%2�,��#!

��"4-�%2�C�#(�#!

�K�"��I�H2H��#�%���2C�!

����1#7/E%K�"-+5��+4��"4 EEG '�0�1#RDE�& I!%&#Q

�#�-�%2*/\I�Kmmn#��+4�*%#�K% 25-59%

�*%#�2J#��#( 78-98%

�R/5%�'/+� 2-41%

�-�%2 EEG )#!H� 24 hr *%#�K% 51%

�-�%2 EEG 8/�42#� 24 hr *%#�K% 34%

�#�-�%2 CT-brain

�$E+5"4& g

�K�"� 45'�(�#6

�30 5#� &"%!*�K�!8"#4K�/ 3�*() �)

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5

$E+5"4& g�#��"4-�%2 CT-brain

�&��*��g47��+#!,�#��%"# 25 'a(������������)

�-�%2�5*%#�R��'�-��#4�(55'�(�#�

��#�&���C�#(� IK�"K�E����2#��gJ#-#/�D4

�+#�#�&���,�7�4$0g�, �D'755�'/ I!�K'

$E+5"4& g�#��"4-�%2 MRI-brain

��#�&��&��� CPS � IK�"-+5��+4-"+�#����1#

��#�&���,�&���� I���1#!#�2��4]

�� refer +����,-� -�&����������

�#�-�%2�/\+���I%K'

�CBC, BUN, Cr, electrolyte, Ca, Mg, PO4, LFT

��/\+��"4�'_�5#4�#!

�98% '�-�

�����������.���

������� 80 %

�+�����������,+�� 2%

���+����/�,�0�1�� 2��

�Liver, renal disease

�#�-�%2�/\+���I%K'

�#�-�%2%���(��5!#���&�� : 'PQ8#

�K�"� �#�-�%2%��3�!��I%K'

�7'�R/K�" D�-E+4

�Therapeutic level ???

�#�-�%2%���(��5!#���&�� : 7�%�#47�EK$

�'�(�#�4#�

���E#4�(55�"4-"+

��#�7'�R/� E#K�"&��K�"-E+4��4%/�(��5!#

� E#&�� H8E�D� I upper limit

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6

$E+5"4& g�#��"4-�%2

��4��!����)#%(�'_���1$+4!#

���5'�(�#�!#���&��8/#!-�%7/E%*%5*,�K�EK�"�

�-E+4�#�-�%2*%#���IJ#���+$+4�#���5'�(�#�!#

�RDE'T%!� 3�*8�\+)#%(� I� R/-"+�(��5!# pregnancy,liver,renal disease

�#�H&E!#���&�� : 'PQ8#

��#����I�H8E!#���&�� H8E��S% $E+5"4& gK�"7�"&��

�$#��#�'�(����R/

�'G�����!#�(8%"#4!#���&��7/(!#+\I�]

��#�-�%2%���(��5!#���&��K�"K�E�J#

�#����I�H8E!#���&�� : 7�%�#47�EK$

��#�%���2C�! ��I�H2 100%

�-E+4� �#�'�(����R/�#�*%5*,��#�&��

�-E+4� �#�'�(����*%#���IJ#���+

�+#2-E+4�"4-�%2%���(��5!#���&��

���E#4*%#�������x.+��� �(8%"#47��!./RDE'T%!

RM

Seizure

AEDs

)#%(/�&��%��L-� : 'PQ8#

�K�"%���2C�!

�%���2C�!&E#

�H8E�#����1#K�" D�-E+4

Srinagarind Med J 1997;12:64Srinagarind Med J 1997;12:64Srinagarind Med J 1997;12:64Srinagarind Med J 1997;12:64----8888

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7

�#����1#� D�-E+4-#�7�%�#4'G�5�-� 7 �#! (28%)

�K�" D�-E+4-#�7�%�#4'G�5�-� 18 �#! (72%)

��#�8-,�#����1#K�" D�-E+4

�7��!.K�"*�� 04 SE

�2J#$�#�!#K�"K�E

)#%(/�&��%��L-�: 7�%�#47�EK$

��#�&��� I�#��#��%"# 5 �#� H8E�4��!%"#2(�'_� SE

�H8E�#����1#-#�7�%�#4�#����1#

��yn#�(%�4+!"#4H�/E&��-"+��\I+4

��(%�4)#%( subtle GTC

Subtle GTC

System : 'PQ8#

�*%#��DE-"+3�*/�&��

�*%#��$E#H27/(����*-�-"+RDE'T%!3�*/�&��

��#�5��8#�2���#��(55�#�H&E!#

��#�5��8#�2���#� OPD

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8

Limited Resources @ Awareness; family, doctor, teacher

@ Attitude; teacher, family, social

@ Appropriate health providerL doctor

L budget

L system

Knowledge in Epilepsy: Khon Kaen

@ What is seizure? 38.5 78.4 94.5

@ Alcoholic withdrawal 12.8 34.3 5.5

@ Genetic disorder 66.7 74.5 53.4

@ 2 years AEDs 33.3 56.9 47.9

@ Stop driving 89.7 79.4 79.5

@ Put something into mouth 80 64 50

@ Total score(50) 16.4 24.5 25.6

Family Teacher Medical Student

������������ ( ��!"� #�)1. f-�, � 1-5 ����2. ������)� GP3. �����+��� ,�+�2���4. ,�!����h�'����������� MRI5. ���� ����� ������f-�����1+�j6. ������k'��'�������l

!�%�&'%()&*+ ,-./0�1�*2��3�4#-

1. ���,�0�)�� �-�� ��������,'�.

2. ����������������-�����,�! �� '�������

3. l����������m�2����� ������+��nj���'�������

4. �������������! �,��� ���,�0���

Compliance with Treatment of Adult Epileptics in a RuralDistrict of Thailand. J Med Assoc Thai 2003;86:46-51.

�Patient-compliance (100%) over 1-year was 56.9%

�Misunderstanding of need long-term treatment 48.4%

�Forgetfulness 16.1%

�Economic problem 12.8%

�Misbelieve 6.5%

�No caregiver to escort them to hospital 6.5%

Anti-epileptic Drugs Available

Type of hospital PB PHT CBZ VPA New AEDs

Regional (%) 100 100 100 100 52.6

General (%) 97.9 97.9 97.9 94.7 16.3

District (%) 100 100 80 20 0

Community (%) 98.7 97.6 67.4 8.2 0.3

PB = phenobarbital, PHT = phenytoin, CBZ =carbamaepine, VPA = valproic acid, New Drugs such as Topiramate, Lamotrigine, Gabapentrin, Vigabatrin

Page 9: How we learn in Management.pdf · 2009-02-12 · Dilantin (100) 1x3 Phenobarb gr I 2x2 Depakine (200) 2x3 ˜ ˆ˜. ˘ ...

9

-��������@ ����� GTC, CPS ���������l

@ ������2,�w���x'��'�������l

@ Epilepsy clinic 200 ��

@ 75 % ����l

@ 25 % ,����.����,'�.

@ 80 % ������1+�j, ����y�f������

System : 7�%�#47�EK$

��"4�����*%#��DE� I D�-E+4-"+'�(&#&�, *�D, 8�"%!4#�

��"4�����*%#��$E#H27/(����*-�� I� -"+'�(&#&�, *�D, 8�"%!4#�

�'��5'�,4�(55�#����1#2���#�3�!!0�RDE'T%!�'_��D�!.�/#4

����I�5�5#�$+4�!#5#/ �)��&��

��'/ I!�%�x *��H8�" ?????

� Clinical practice guideline : practical ? Yes or No

� �+. ���f'&���������l�y���� CPG ���

����2���� -�f'� �+. �����l�y����

Easy Epilepsy Clinic

Pitfalls of CPG

Page 10: How we learn in Management.pdf · 2009-02-12 · Dilantin (100) 1x3 Phenobarb gr I 2x2 Depakine (200) 2x3 ˜ ˆ˜. ˘ ...

10

Page 11: How we learn in Management.pdf · 2009-02-12 · Dilantin (100) 1x3 Phenobarb gr I 2x2 Depakine (200) 2x3 ˜ ˆ˜. ˘ ...

11

THANK YOU FOR YOUR INTEREST

CASE DISCUSSION

��/�w����

�����'&����. 22 �z )�� �-�� 10 �z

���������� y�,���

1��������� 6 ,�!��

��,����,����� 1 ��

���+� nystagmus

��2���,+� �,���

1 ,�!�� �2, �2�����������������������1 �����'j �������-��' ����h��.����h��� -�� ����f'�� dilantin ���h� 2 3 ,�m��������-������������� 2 4 ���h��� 2 ��������h�'�� 24 ,�m�f� 2 ������,�m��.��y�,���

Page 12: How we learn in Management.pdf · 2009-02-12 · Dilantin (100) 1x3 Phenobarb gr I 2x2 Depakine (200) 2x3 ˜ ˆ˜. ˘ ...

12

Case Study

RDE'T%!&#!+#!, 45 'a ��52E#4

CC: &��5"+!�#�$0g� 1 ��\+�

PI : Case CPS � +#�#��E+4K8E +#/(%#� 8/�42#�� +#�#�&�� 5#4*��g4'a���#8+��(2#!$"#%$+48�D"5E#� H�&"%4 1 ��\+� � +#�#��#�$0g�

- Q#-��J#RDE'T%!�"43�4�!#5#/2�-�%&7/E% 7��!.�"4-�%�#��5�#����1#-"+

Problem

1. Intractable seizure

2. Psychotic symptom

Patient with chronic and

active epilepsy

1. Review diagnosis and etiology

� history

� EEG

� neuroimaging

� other investigation

2. Classify epilepsy

3. Review compliance

History

1. Q#-�H8ERDE'T%!8!,��#�!#���&��

2. ���1#�#4K�!�#�-�.

Psychotic symptom and epilepsy

��/�w����

�����-���. 25 �z ��-�+�������GTC 1 �z

Dilantin (100) 1x3

Phenobarb gr I 2x2Depakine (200) 2x3���.������������

Page 13: How we learn in Management.pdf · 2009-02-12 · Dilantin (100) 1x3 Phenobarb gr I 2x2 Depakine (200) 2x3 ˜ ˆ˜. ˘ ...

13

�%&'�

1. ���.������������

2. �y��������������-��l�� 3 ��

1����������

1. ����2�������-��

2. ��2,��� compliance

3. � local '�!� original

� �����2,���

1. �2�������-��� y�'���.�-���

2. Poor compliance

3. � local

��������f'��

1. ����,�0� monotherapy, original

2. Dilantin (100) 3 ,�m��������

H3#--��I40*�-#�4#-1. Monotherapy

2. Low initial dose

3. Individualized

4. Brand name

5. Assessment

��/�w����

�����-�����. 38 �z

������,�0�)�� �-���� 8 �z

����������� y�,��� 1�����.�������

Page 14: How we learn in Management.pdf · 2009-02-12 · Dilantin (100) 1x3 Phenobarb gr I 2x2 Depakine (200) 2x3 ˜ ˆ˜. ˘ ...

14

��2���,+� �,���

������������� 1 2,�������

���� amitriptyline ��� ��

1�'���������{���1 2 ����� ��

)����,�����y�f'� ��������� febrile convulsion

�LMH�

1. N�O�����N0�I�

2. �LMH���, ��#�

3. 2&PQ��,�

1����������

1. 1�2�y�����x�������

2. 1�2�y����f-���! �|

3. 1�2�y������,+w���+��nj

4. 1�2�y� febrile convulsion

Case Study

RDE'T%!8Q�4+#!, 18 'a ����0�1#CC : &��5"+!$0g��# 1 ��\+�PI : Case CPS �# 2 'a �#�8-,2#� hippocampal sclerosis ���1#�E%! valproic acid 1500 ��./%��, carbamazepine 1200 ��./%�� *%5*,�+#�#�K�E� 7-" 2 ��\+�� IR"#��#� +#�#�&��5"+!�#�$0g� 1-2 *��g4-"+%�� 7�"204�#K'�57��!.��,4����8#�*� -�%2�(��5!#�5%"# +!D"H��(��5�D4-#�� I-E+4�#�204���I�!#���&��&���� I 3 *\+ lamotrigine 7-"+#�#�K�"� $0g� 204�#�#-�%2� I 3�4�!#5#/�� �*�����.

Problem

New onset of intractable seizure

Patient with chronic and

active epilepsy

1. Review diagnosis and etiology

� history

� EEG

� neuroimaging

� other investigation

2. Classify epilepsy

3. Review compliance

Page 15: How we learn in Management.pdf · 2009-02-12 · Dilantin (100) 1x3 Phenobarb gr I 2x2 Depakine (200) 2x3 ˜ ˆ˜. ˘ ...

15

History

1. �+5'�(2J#��\+�$#��# 2 ��\+�

2. Urine pregnancy test: positive

3. Abortion

HM��R&* 28 �T Q#U����V+ 35 !#�O�H+

Epilepsy 2 �T,well controlled with CBZ

GTC 3 ��#U� H3#���-��3'%*� CBZ PB

()&*+X�-���V+(�Y�Z�IH0��3'%*�

��/�w����

�LMH�

1. �����N0�I��-'%*�-# *�&'%&��

2. -�����(.���, ��#�

��������

1. 1�2�y���������� l������

2. �����1���������

N0,)����[�

1. -��O/(3./0�1�*2��3�4#-&'%Q#U����V+

2. .3N,�2��3�4#-Q\,-��Q#U����V+

3. -����# ��3'%*�*�

Complications of Pregnancy in Epilepsy

Bleeding

Premature separation of the placenta

Toxaemia of pregnancy and pre-eclampsia

Miscarriage

Intrauterine growth retardation, low birth weight

Still birth and perinatal mortality

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16

Complications of Pregnancy in Epilepsy

Premature labour

Breech and other abnormal presentations

Forceps delivery, induced labour, Caesarean sectionPrecipitant labour

Psychiatric disturbance

Management in Pregnancy

1. Monotherapy

2. R�\Q0,���3'%*�*� AED

3. Vit B ���(3Y Folic acid 5 �-./�#�

4. Valproate/ carbamazepine

- ultrasound 16-18 wk

- alpha fetroprotein

5. -\,��3,O 1 wk

- admit

- Vit K1 20 �-./�#�

6. Drug level

7. Normal labor, except SE

Management in Pregnancy

4�*R&* 30, nephrotic syndrome 3 �Ob,�, alb 2.2 gm/dL�#-P�O0�* prednisolone RO0.3R�\O'R,�����3b,O (3Y 2nd GTC 3 ��#U�Pulmonary TB, AFB positiveCT-brain: granulomatous lesionAnti TB drug: IRZE + phenytoin 300 mg/day4#-dUZ� Q����YO# *�RO0 12 ug/dLPhenytoin ���� 400 mg/day3 �#�Q\,���',�-�������'*� �O���d nystagmus, cerebellar sign

-�['ef-P� N0,)����[�

1. N0, \�4'U-��Q����YO# *�

2. N0,����Y�#�I�./0�1�* hypoalbuminemia,

renal disease

3. Drug interaction:anti TB drug vs AEDs

4. -����# *� phenytoin

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17

Indications for Serum Level Monitoring

1.Poor response : to identify unusual pharmacokineticpatterns or poor compliance

2.Physiological or pathological conditions: changing pharmacokinetics(hepatic disease,kidney disease,pregnancy, )

3.Establishing drug toxicity

Indications for Serum Level Monitoring

4.Minimizing the problems caused by

non-linear kinetics with phenytoin

5.Minimizing the problems caused by

drug interactions

Hypoalbumin

Corrected phenytoin level 22

( ) 1.0/4.4

0.1 -1

ionconcentrat observed

+

×

=

dlgm

albPH

Phenytoin

CYP2C9 > CYP2C19

HPPH

glucuronide

Urine

Inducer(rifampin, CBZ)

Inhibitor (INH,cimetidine, omeprazole)

300 mg

325 mg

330 mg

350 mg


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