Treat underlying disease e.g alcohol, mesial temporal sclerosis
Avoid precipitating factors e.g. sleep deprivation, alcohol
Drug therapy -aim for monotherapy
-continue for 2-3 years at least
Treat complications -depression
-social stigma
Support Socially -Education e.g. emergency management of seizure, don’t swim/dive alone at all
-Contact with Epilepsy association
-Driving e.g. chronic epilepsy need 2 yrs seizure free, isolated seizure/ recent diagnosis 3-6 months seizure free
-Work ie. Work safety issues e.g. usse of machinery
-Pregnancy Contraception- There is decreased efficacy of OCP with carbamazepine, phenytoin, barbiturates not valproate therefore will need high dose, depot or non-hormonal
Drugs-Pregnancy decreases the bioavailability of phenytoin, phenobarbitome and carbamazepine therefore may have to measure the levels every 4-6 weeks
Fetus-Overall the harm potential of not giving drugs is greater than the side effects of drug treatment although this needs to be discussed with the patient. The risk is 3-5% of neural tube defects with valproate, phenytoina dn barbiturates are also associated with cardiac abnormailites and cleft lip. All women should take 5mg of folate 1 month before and 3 months after contraception. Vitamin K given orally in the last 2 weeks and an injection to the infant as there can be vit K deficiency. Do not discourage from breast feeding. Educate about higher obstetric risks eg hyperemesis gravidarum, premature labour, assisted delivery, stillbirth. Try and maintain on monotherapy. Can offer perinatal monitoring with fetal ultrasound and AFP at 15-20w of gestation, especially if on valproate. Note 30% of women have increased seizures in pregnancy, 20% decrease and others no change.
Investigations may include FBC, EUC, LFT, Toxicology screen, CT, MRI
Treatment Remember to continually assess side-effects, compliance, serum levels if necessary. 70% of epileptics will be controlled on 1 drug, A further 15% will be controlled on 2-3 drugs. The final 15% will need multiple combinations, surgery or be refractory.
Primary Generalised Valproate See below
Lamotrigine Insomnia, dizziness, skin rash, non-sedating
Topiramate Cognitive slowing, somnolence, weight loss, mood change
Partial Carbamazepine Skin rash, drowsiness, hypoNa, abnormal LFTs
Phenytoin Drowsiness, skin rash, gum hypertrophy, hirsutism, ataxia
Valproate Weight gain, GIT disturbances, hepatotoxicity, tremor, hair thinning, thrombocytopenia
Addons Gabapentin(partial) Few interactions, renal excretion, slight weight gain, useful in transplant patients and liver disease
Lamotrigine(partial) As above
Topiramate (any)
Vigabatrin Visual field loss!
Reasonable to consider discontinuation if seizure free for 2 years. Decrease dose by a third every 2-4 weeks.