EPILEPSY

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

Investigations Fasting blood sugar Fbc U&E LFT’s TFT’s

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

Epilepsy Prevalence 4-10 per 1000 population 50% female Life long condition

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

Preconceptual advice Sudden stooping of AED’s may cause SUDEP Status epilepticus

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