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

2. 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)

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

4. 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

5. 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

6. 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

7. 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

8. 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)

9. 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

10. 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.

11. 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)

12. 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