Epilepsy Key slides Saint Valentine- Patron Saint of Epilepsy, martyred for the sake of love

What is epilepsy. CKS PRODIGY Guidance What is epilepsy? CKS PRODIGY Guidance. February 2006; NICE CG 20, October 2004 Epilepsy Characterised by recurrent, unprovoked seizures Should be viewed as a symptom of an underlying neurological disorder and not as a single disease entity Epileptic seizure Brief disturbance of consciousness, behaviour, emotion, motor function, or sensation that is due to abnormal electrical discharge in the brain Classification Epileptic seizure type (clinical presentation) Epileptic syndrome (underlying neurological disorder)

Epilepsy seizure types NICE CG 20, October 2004; National Society for Epilepsy www.epilepsynse.org.uk (accessed March 2008) Generalised Tonic-clonic Absence Atonic Myoclonic Partial (focal) Simple partial Complex partial Mixed Status epilepticus

Epidemiology CKS PRODIGY Guidance, February 2006; NICE CG 20, October 2004 Most common serious neurological condition in UK Prevalence on treatment 1 in 200 Lifetime prevalence 2–5% of population Annual incidence rate 50/100,000 (highest in children and the elderly) Up to one-third of people with learning disability have epilepsy Cause often unknown Seizure type and frequency 60% tonic-clonic 20% complex partial 12% mixed tonic-clonic and partial 3% simple partial <5% absence, myoclonic and others

Prognosis CKS PRODIGY Guidance, February 2006; SIGN 2003 Recurrence risk after a first seizure varies greatly Overall risk of recurrence 30–40% 13%–40% if normal EEG Up to 90% if abnormal EEG, or with congenital neurological defects Recurrence is most likely in the first 12 months, and falls to less than 10% after 2 years Treatment with AEDs halves the recurrence risk Remission of seizures is common 9 years after diagnosis ~ 70% of people will have been seizure-free for the preceding 3 years and only ~ 30% will still be on medication Of those who continue to have seizures, some will have recognisable cerebral abnormalities and severe and persistent types of epilepsy

General principles of epilepsy management NICE Clinical Guideline (adults and children) NICE CG 20, October 2004 Information for patients and families/carers Diagnosis and investigations Management Initial and ongoing drug treatment (Technology Appraisals) Withdrawal of drug treatment Referral for surgery Status epilepticus Special groups and consideration Patient review Implementation and audit

Initial treatment NICE CG 20, October 2004 Initiation of AED therapy only when diagnosis confirmed - generally after second epileptic seizure (A) AED therapy after first unprovoked seizure if: (B) Neurological deficit EEG indicates unequivocal epileptic activity Risk of further seizure considered unacceptable Brain imaging shows structural abnormality The decision to start an AED should be made by the patient and an epilepsy specialist (largely decided by risk of further seizures) (GPP) Overall, recurrence risk after first seizure is 30–40% Greatest risk in first 12 months Risk falls to <10% after 2 years Some patients will continue to have seizures despite treatment Some patients may decide not to undergo treatment following a discussion of the risks and benefits

Initial treatment NICE CG 20, October 2004 Prescribers should establish base-line biochemistry and full blood count prior to commencing AED therapy (GPP) Monotherapy wherever possible (A) If initial therapy unsuccessful, monotherapy with another drug can be tried (caution needed in change over) (A) Second drug can be another first-line or second-line drug Initiate second drug and increase to adequate or maximum tolerated dose before tapering off first-line drug (GPP) Combination therapy should only be considered where no seizure freedom with monotherapy (A) Continuing AED therapy should be planned by the specialist (GPP)

NICE guidance: Newer AEDs NICE TA 76 & 79, 2004 Newer AEDs (gabapentin, lamotrigine, levetiracetam, oxcarbazepine, tigabine, topiramate▼ and vigabatrin*) within their licensed indications are recommended in those who have not benefited from treatment with older agents such as carbamazepine or sodium valproate, or for whom older drugs are unsuitable because: Contraindications Possible interactions with other drugs Known to be poorly tolerated by the individual Females of childbearing potential (* vigabatrin: adjunct in partial seizures, 1st line monotherapy in infantile spasm) Topiramate is a ‘black triangle’ drug Ref. SPC Topiramate accessed March 2008

NICE guidance: Drug options by seizure type NICE CG 20, 2004 1st Line drug 2nd Line drug Other drugs to consider Drugs to avoid (worsen seizures) Generalised tonic-clonic CBZ, SVP LTG*, TOP* CLB, LEV, OXC ACZ, CLN, PHE, PHY, PRI TIG, VIG Absence ETS, SVP LTG* CLB, CLN, TOP - CBZ, GBP, OXC, TIG, VIG Myoclonic SVP (TOP in child/adolescent) CLB, CLN, LTG, LEV, PIR, TOP Tonic CLB, CLN, LEV, TOP ACZ, PHE, PHY, PRI CBZ, OXC Atonic ACZ, PHE, PRI CBZ, OXC, PHY Focal + secondary generalisn LTG*, TOP*, OXC* CLB, GBP, LEV, PHY, TIG ACZ, CLN, PHE, PRI KEY: CBZ=carbamazepine; SVP=sodium valproate; LTG=lamotrigine; TOP=topiramate; ETS=ethosuximide; OXC=oxcarbazepine; CLB=clobazam; CLN=clonazepam; LEV=levetiracetam; PIR=piracetam; GBP=gabapentin; ACZ=acetazolamide; PHE=phenobarbital; PHY=phenytoin; PRI=primidone; TIG=tiagabine; VIG=vigabatrin *=under circumstances outlined in NICE TAs of AEDs.

Withdrawal of drug treatment NICE CG 20, October 2004 Patients should be seizure free for at least 2 years (A) Decision to withdraw treatment taken with individual (family/carers) and specialist (A) Risks and benefits of continuing or withdrawing treatment Individual risk of seizure recurrence on and off treatment (prognostic index of seizure recurrence act as a guide only) Withdrawal must be managed by/under supervision of specialist (GPP) Withdrawal should be slow (at least 2–3 months) and one drug at a time if on combination therapy (D) Plan needed in case of seizure recurrence (GPP)

Epilepsy Summary Epilepsy is the most common serious neurological condition in the UK, and can have profound psychological and physical effects Correct diagnosis is essential, but can be very difficult Most patients have potential to be seizure free but some patients will continue to have seizures Little evidence that newer AEDs offer benefits over older, more established medicines but costs often higher All patients should have a comprehensive care plan and regular review There is a long history of deficiencies in the standards of care for patients with epilepsy, and on a population level there is evidence of waste of NHS resources