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Epilepsy Mx
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<<forEachTiddler where 'tiddler.tags.contains(context.inTiddler.title)' sortBy tiddler.title ascending write '"*[["+tiddler.title+"]]\n"'>> <<tiddler AutoRefresh with: force>> ''Aim '' seizure free no or acceptable SE ''Principles'' use one drug if possible (75% control with one drug) second drugs may dec seizures and will increase SE (adding 2nd line dec fits by 50% in 30% people) needs neurologist no one drug is better - need to try education / behaviour modification / family therapy - all help psychosocial functioning but don't dec seizures CBT - helps depression but not seizures nor always psychosocial start drug with pt agreement with neurologist at low dose and titrate up - usually after 2 seizures (after 1 refer to neurology - 2WW) start 1st drug after 1 seizure IF neuro deficit, brain lesion, status, EEG shows generalized spike wave, pt/family request consider stopping after >2y seizure free and tail off over 2-3/12 usually ... partial seizures - ''Carbamazepine'' / Lamotrigine generalized seizures - ''Valproate'' / Lamotrigine / Carbamazepine / (Levitiracetum) Absence seizures (petit mal) - ''Valproate'' / Ethosuximide (Carbamazepine may exacerbate) Myoclonic seizures - ''Valproate'' / Clonazepam / Lamotrigine Stopping drugs - consider at 2 yrs no seizure with 2-3/12 tail High rate psychosocial disfunctioning - low self esteem, anxiety, depression, social difficulty Poor compliance - 1/3rd not seizure free as don't take Rx - poor understanding, lack of / misinterpretation of instructions education - inc knowledge, adjustment, psychosocial function Relaxation and behaviour modification also reduces anxiety and improves functioning Family counselling - helps adjustment CBT - decreases anxiety and depression Of no benefit - yoga, biofeedback, relaxation alone ''Drugs'' common carbamazepine, phenytoin, lamotrigine, valproate (also clobazam and phenytoin - neither 1st line) 2nd line Pregabalin, gabapentin, levetiracetum, topiramate, oxycabazepine, tigabine, vigabatrin, zonisamide, lacosamide ''Side effects'' All - sedation (sleepy/fatigue), headache, ataxia, dizziness, (SHAD) and maybe suicidal ideation can cause paradoxical inc in seizure frequency and severity idiosyncratic - agranulocytosis, Steven-johnson, aplastic anaemia, pancreatitis, serum sickness, allergic dermatitis, liver failure (asap sal) teratogenic - NTD, cleft lip/palate - 1.5% background, 2.5% carbamazepine, 5% lamotrigine, 7% valproate (worst around conception / early 1st T) also risks to fetus of seizure - needs to be maternal decision eg Valproate - weight gain, (nine) alopecia, tremor, - 9% stopped (WHAT) Carbamazepine - rash, diplopia - 18% stopped Vigabatrin - 40% get concentric visual field defects - can be irreversible ''Surgery '' useful in drug resistant pts with complex partial seizures decrease seizure rate and improves psychosocial Vagus nerve stimulation - on L - electrode around nerve and battery pack on ant chest wall - regular pulses and additional manual ones (via magnet) may cause hoarseness, cough, dyspnoea, pain, paraesthesia When to refer If suspect - refer to confirm diagnosis - 2WW If poor control - refer If female of child bearing age - refer ie mostly managed in secondary care role for GPSI
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Epilepsy