Seizures Victoria Elliot

Outline Brief recap Management update Advantages and disadvantages of common antiepileptics Status epilepticus DVLA guidelines

Epilepsy Between 362, ,000 people affected in UK Up to 125,000 people diagnosed incorrectly 2/3 have well controlled epilepsy Costs the NHS £2 billion per year

Overview Generalised, simple partial or complex partial Aetiological and precipitating factors include genetic, developmental abnormalities, trauma/surgery, pyrexia, mass lesions, vascular, drugs, inflammatory, metabolic, degenerative.

Overview Diagnosis –EEG –CT/MRI –Bloods

Management General principles First line agents –Focal seizures-Carbamazepine or Lamotrigine –Generalised seizures-Sodium Valproate –Absence/myoclonic-Sodium Valproate

Management 2 2 nd line –Partial- Oxcarbazepine, Sodium valproate or levetiractam –Generalised- Lamotrigine if valproate not effective then carbamazepine or oxcarbazepine.

Management 3 Adjunctive treatment –Focal-carbamazepine, clobazam, gabapentin, lamotrigine or topiramate –Generalised- Clobazam, kepra, topiramate

Principles in palliative care Treat after 1 st seizure Enzyme inducers can cause an interaction with chemotherapy. Commence at lower than recommended doses as they are better tolerated. Avoid using more than 1 drug

Management 1 st line –Oxcarbazepine –Valproate –Phenytoin 2 nd line –Switch to another 1 st line drug or use Levetriacetam

Phenytoin Advantages –Can be rapidly titrated –Can be given IV –Safer than other antiepileptic drugs in renal impairment –Levels are available and can be helpful Disadvantages –Multiple interactions –Can become toxic –Can cause side effects such as rashes and gum hypertrophy

Sodium Valproate Advantages Can be titrated rapidly Can be given IV Useful in most seizure types Can help weight gain Disadvantages –Can cause liver failure particularly if pre- existing liver disease or deranged LFTs. –Teratogenic –Lower doses and slower titration needed in renal impairment –Drug interactions possible as is an enzyme inhibitor

Levetriacetam Advantages –Effective for large range of seizure types –Usually well tolerated in comparison to other drugs –Possibly increased toxicity when in combination with carbamazepine/ phenytoin –PO and IV doses identical Disadvantages –Commonly cause fatigue and drowsiness –Dose reduction required in renal impairment

Oxcarbazepine Advantages –Useful for most seizure types Disadvantages –Caution in heart disease(arrhythmias/ cardiac failure) –OCP/lamotrigine and phenytoin metabolism may be affected –Commonly cause fatigue, n+v, headache and dizziness –Can cause hyponatraemia and Na needs to be monitored closely –Only available orally –Halve dose if eGFR<30

Status Epilepticus ABC Exclude hypoglycaemia Lorazepam 4mg or midazolam 10mg Repeat benzodiazepine after mins Phenobarbital If appropriate transfer to ICU for GA

DVLA recommendations Updated may 2012 For car/bike licences –If first seizure can drive afer 6 months but otherwise must be seizure free for 1 yr before being allowed to drive –If nocturnal epilepsy must refrain for 1 yr but if nocturnal fit 3 yrs ago and no daytime seizures may drive despite the fact nocturnal fits may continue –Must take treatment and have regular follow up

DVLA recomendations For HGV licences –Must be seizure free for 10 yrs –If only 1 seizure and seizure risk thought to be less than 2%/annum can drive again after 5 yrs –Must not be taking any antiepileptic medication