Management Antiepileptic Drug Therapy – Goal: completely prevent seizures without causing untoward side effects Treat the underlying conditions – Reverse the problem and prevent its recurrence

Drug of Choice for Epilepsy Patient’s Medication Upon Admission Phenytoin (Dilantin) 100mg/cap TID ILAE Treatment Guidelines, 2006 Effectiveness-outcome evidence – Based on RCT efficacy and effectiveness evidence, CBZ, LTG, OXC, PB, PHT, TPM, and VPA are possibly efficacious/effective as initial monotherapy for adults with GTC seizures and may be considered for initial therapy in selected situations (level C) (Glauser, et al. 2006) Glauser, T, Elinor BM, Blaise Bs, et. al. "ILAE Treatment Guidelines: Evidence-based Analysis of Antiepileptic Drug Efficacy and Effectiveness as Initial Monotherapy for Epileptic Seizures and Syndromes." (International League Against Epilepsy) 27, no. 7 (2006):

Maintenance Medications Home Medications Phenytoin 100mg/cap TID Levetiracetam 500mg/tab BID Citicoline 1gm/tab BID ASA 80 gm/tab OD Current Perspectives in Epilepsy Treatment: Focus on Monotherapy, 2006 Initial treatment of epilepsy should begin with AED monotherapy If initial trial fails, try monotherapy with a second AED Combination therapy should be considered only if the patient fails at least 2 monotherapy trials Pellock, John, and Michael Privitera. Current Perspectives in Epilepsy Treatment: Focus on Monotherapy. CME Discovery, USA: ArcMesa Educators and Scinexa, LLC., 2006.

Maintenance Medications Home Medications Phenytoin 100mg/cap TID Levetiracetam 500mg/tab BID Citicoline 1gm/tab BID ASA 80 gm/tab OD ILAE Treatment Guidelines, 2006 For patients with newly diagnosed or untreated epilepsy which AEDs have the best evidence for use as initial monotherapy? RCT efficacy and effectiveness: CBZ, LTG, OXC, PB, PHT, TPM, and VPA are possibly efficacious/effective as initial monotherapy for adults with GTC seizures and may be considered for initial therapy in selected situations (level C) (Glauser, et al. 2006) Glauser, T, Elinor BM, Blaise Bs, et. al. "ILAE Treatment Guidelines: Evidence-based Analysis of Antiepileptic Drug Efficacy and Effectiveness as Initial Monotherapy for Epileptic Seizures and Syndromes." (International League Against Epilepsy) 27, no. 7 (2006):

Maintenance Medications Home Medications Phenytoin 100mg/cap TID Levetiracetam 500mg/tab BID Citicoline 1gm/tab BID Current Perspectives in Epilepsy Treatment: Focus on Monotherapy, 2006 Levetiracetam – Sodium channel blocker – No important interactions with other antiepileptic drugs Pellock, John, and Michael Privitera. Current Perspectives in Epilepsy Treatment: Focus on Monotherapy. CME Discovery, USA: ArcMesa Educators and Scinexa, LLC., 2006 Fisher, Marc, Antoni Davalos, Andreas Rogalewski, et. al. Toward a Multimodal Neuroprotective Treatment of Stroke. Stroke (American Heart Association) 2006;37; Toward a Multimodal Neuroprotective Treatment of Stroke, 2006 Citicoline RCTs show that citicoline improves neurological outcome after stroke meta-analysis indicates that there might be an effect for the subgroup of moderate to severe ischemic strokes Combinations with either growth factors or thrombolytics produce true synergistic effects  reduced mortality and infarct volume

Post-stroke Maintenance Medications Maintenance since Jan 2010, post stroke – ASA 80mg/tab OD – Dipyrimadole (Persantine) 200mg/tab BID International Stroke Trial (IST, Lancet 1997;349: ) – Aspirin treated patients had slightly fewer deaths at 14 days, significantly fewer recurrent ischemic strokes at 14 days and no excess of hemorrhagic strokes Dipyridamole for Preventing Stroke and Other Vascular Events in Patients With Vascular Disease: An Update – Compared with control, dipyridamole had no clear effect on vascular death (RR 0.99, 95% CI, 0.87 to 1.12). – Compared with control, dipyridamole appeared to reduce the risk of vascular events (RR 0.88, 95% CI, 0.81 to 0.95). – Routine use of dipyridamole alone as first line antiplatelet treatment is not supported. The combination of dipyridamole plus aspirin is associated with a lower risk of further vascular events than aspirin alone.

Discontinuation of Anticonvulsants Specchio and colleagues – After 2 years on a single anticonvulsant during which no seizures had occurred, the rate of relapse was 40% 2 and a half years later and 50% at 5 years after discontinuation – For patients remaining on medication, seizure recurrence rate is 20%

Discontinuation of Anticonvulsants When patient has been free of seizures for a prolonged period (?) A safe plan, applicable to most forms of epilepsy, is to obtain an EEG whenever withdrawal of medication is contemplated. If the tracing is abnormal by way of showing paroxysmal activity, it is generally better to continue treatment.

PUBLIC HEALTH PERSPECTIVE