Seizures

Victoria Elliot

Outline

• Brief recap

• Management update

• Advantages and disadvantages of common antiepileptics

• Status epilepticus

• DVLA guidelines

Epilepsy

• Between 362,000-415,000 people affected in UK

• Up to 125,000 people diagnosed incorrectly

• 2/3 have well controlled epilepsy

• Costs the NHS £2 billion per year

Overview

• Generalised, simple partial or complex partial

• Aetiological and precipitating factors include genetic, developmental abnormalities, trauma/surgery, pyrexia, mass lesions, vascular, drugs, inflammatory, metabolic, degenerative.

Overview

• Diagnosis– EEG– CT/MRI– Bloods

Management

• General principles

• First line agents– Focal seizures-Carbamazepine or Lamotrigine– Generalised seizures-Sodium Valproate– Absence/myoclonic-Sodium Valproate

Management 2

• 2nd line– Partial- Oxcarbazepine, Sodium valproate or

levetiractam– Generalised- Lamotrigine if valproate not

effective then carbamazepine or oxcarbazepine.

Management 3

• Adjunctive treatment– Focal-carbamazepine, clobazam, gabapentin,

lamotrigine or topiramate– Generalised- Clobazam, kepra, topiramate

Principles in palliative care

• Treat after 1st seizure

• Enzyme inducers can cause an interaction with chemotherapy.

• Commence at lower than recommended doses as they are better tolerated.

• Avoid using more than 1 drug

Management

• 1st line– Oxcarbazepine– Valproate– Phenytoin

• 2nd line– Switch to another 1st line drug or use

Levetriacetam

Phenytoin

• Advantages– Can be rapidly titrated– Can be given IV– Safer than other

antiepileptic drugs in renal impairment

– Levels are available and can be helpful

• Disadvantages– Multiple interactions– Can become toxic– Can cause side effects

such as rashes and gum hypertrophy

Sodium Valproate

• Advantages• Can be titrated rapidly• Can be given IV• Useful in most seizure

types• Can help weight gain

• Disadvantages– Can cause liver failure

particularly if pre-existing liver disease or deranged LFTs.

– Teratogenic– Lower doses and

slower titration needed in renal impairment

– Drug interactions possible as is an enzyme inhibitor

Levetriacetam

• Advantages– Effective for large range of

seizure types– Usually well tolerated in

comparison to other drugs– Possibly increased toxicity

when in combination with carbamazepine/ phenytoin

– PO and IV doses identical

• Disadvantages– Commonly cause fatigue

and drowsiness– Dose reduction required in

renal impairment

Oxcarbazepine

• Advantages– Useful for most seizure

types

• Disadvantages– Caution in heart

disease(arrhythmias/ cardiac failure)

– OCP/lamotrigine and phenytoin metabolism may be affected

– Commonly cause fatigue, n+v, headache and dizziness

– Can cause hyponatraemia and Na needs to be monitored closely

– Only available orally– Halve dose if eGFR<30

Status Epilepticus

• ABC

• Exclude hypoglycaemia

• Lorazepam 4mg or midazolam 10mg

• Repeat benzodiazepine after 10-20 mins

• Phenobarbital

• If appropriate transfer to ICU for GA

DVLA recommendations

• Updated may 2012• For car/bike licences

– If first seizure can drive afer 6 months but otherwise must be seizure free for 1 yr before being allowed to drive

– If nocturnal epilepsy must refrain for 1 yr but if nocturnal fit 3 yrs ago and no daytime seizures may drive despite the fact nocturnal fits may continue

– Must take treatment and have regular follow up

DVLA recomendations

• For HGV licences– Must be seizure free for 10 yrs– If only 1 seizure and seizure risk thought to be

less than 2%/annum can drive again after 5 yrs

– Must not be taking any antiepileptic medication