Epilepsy
Epilepsy is diagnosed when a person experiences two or more unprovoked seizures occurring over 24 hours apart. It encompasses various seizure types, including generalized tonic-clonic, absence, myoclonic, tonic, and atonic seizures, with causes ranging from genetic factors to structural, metabolic, immune, and unknown factors. Treatment primarily involves antiseizure drugs, with approximately 50% of patients achieving seizure freedom on their initial medication. Initial drug selection considers factors like efficacy, side effects, drug interactions, and patient preferences, and treatment should include patient education on medication compliance and side effect monitoring.
2024-01-01 00:51:00 - Editor
Understanding Epilepsy: Definition and Types
Epilepsy is defined as having two or more unprovoked seizures, either focal or generalized, occurring more than 24 hours apart. It is associated with an increased risk of mortality. Various types of generalized seizures include tonic-clonic (grand mal) seizures, characterized by sudden loss of consciousness and muscle stiffening followed by jerking movements, and absence seizures, usually observed in children and characterized by brief episodes of staring and lip smacking. Myoclonic seizures involve sudden arm muscle contractions, and tonic seizures result in muscle stiffening and impaired consciousness. Atonic seizures lead to sudden loss of muscle control, causing falls. Epilepsy can be caused by genetic, structural (e.g., cerebrovascular disease, brain tumors), metabolic, immune, or unknown factors. (1, 2, 3)
Treatment of Epilepsy and Initial Drug Therapy
About 50% of patients with epilepsy become seizure-free with their first antiseizure drug. The choice of medication depends on various factors, including drug efficacy, side effects, pharmacokinetics, cost, and potential drug-drug interactions. Phenytoin, carbamazepine, and phenobarbital are known for problematic interactions with drugs like warfarin, anticancer agents, and certain antibiotics. The etiology of epilepsy and patient-specific factors like age and comorbidities also influence treatment choices. Valproate and lamotrigine are noted for their effectiveness in treating focal epilepsy. (4, 5, 6)
Side Effects and Quality of Life Considerations
Antiseizure drug side effects significantly impact the quality of life. While some side effects are common across this class of drugs (drowsiness, dizziness), others are specific to individual medications. (7)
Specific Antiseizure Medications and Dosage
Treatment should begin with a single drug. Lamotrigine is preferred for focal epilepsy, while valproate is chosen for generalized epilepsy. Detailed dosage guidelines for lamotrigine and valproate are provided, along with alternative options such as phenytoin, carbamazepine, gabapentin, and topiramate. (8)
Patient Education, Monitoring, and Compliance
Patients and their families should be educated about epilepsy and the importance of adherence to medication to reduce mortality risk. Regular monitoring for side effects and blood levels of certain drugs is crucial. Patients should record seizure activities and consult their physician before starting new medications. Monitoring for side effects like CNS depression, skin reactions, and psychiatric symptoms is essential. (8, 9)
References
1-Middleton DB. Seizure disorders. In: Taylor RB, editor. Family Medicine:
Principles and Practice. 6th ed. New York: Springer-Verlag; 2003.
2-Bazil CW, Morrell MJ, Pedley TA. Epilepsy. In: Rowland LP,
editor. Merritt’s Neurology. 11th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. pp. 990–1008.
3-atum WO, Benbadis SR, Vale FL. The neurosurgical treatment of epilepsy. Arch Fam Med. 2000;9:1142–1146.
4-McNamara JO. Drugs effective in the therapy of the epilepsies. In: Hardman JG, Limbird LE, Molinoff PB, Ruddon RW, editors. Goodman & Gilman’s The Pharmacological Basis of Therapeutics. 9th ed. New York: McGraw-Hill; 1999. pp. 461–486.
5-Dulac O, Leppik IE, Chadwick DW, et al. Starting and stopping treatment. In: Engel J Jr, Pedley TA, editors. Epilepsy: A Comprehensive Textbook. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2008. pp. 1301–1309.
6-Scottish Intercollegiate Guidelines Network (SIGN)Guideline No
70. Diagnosis and Management of Epilepsy in Adults Edinburgh, U.K.SIGN; 2003Available at: www.sign.ac.uk.
7-Lang DG, Wang CM, Cooper BR. Lamotrigine, phenytoin, and carbamazepine interactions on the sodium current present in N4TG1 mouse neuroblastoma cells. J Pharmacol Exp Ther. 1993;266:829–835.
8-Stephen LJ, Brodie MJ. Selection of antiepileptic drugs in adults. Neurol Clin. 2009;27:967–992.
9- American Academy of Neurology Guideline summary for clinicians: Efficacy and tolerability of the new antiepileptic drugs, part 1: Treatment of new onset epilepsy. Available at: http://aan.com/professionals/ practice/pdfs/clinician_ep_onset_e.pdf