Management
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Management. Antiepileptic Drug Therapy Goal: completely prevent seizures without causing untoward side effects Treat the underlying conditions Reverse the problem and prevent its recurrence. Medical Management. Current Perspectives in Epilepsy Treatment: Focus on Monotherapy , 2006

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Management

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Management

Management

  • Antiepileptic Drug Therapy

    • Goal: completely prevent seizures without causing untoward side effects

  • Treat the underlying conditions

    • Reverse the problem and prevent its recurrence


Medical management

Medical Management

  • Current Perspectives in Epilepsy Treatment: Focus on Monotherapy, 2006

    • Initial treatment of epilepsy should begin with AED monotherapy

    • If initial trial fails, try monotherapy with a second AED

    • Combination therapy should be considered only if the patient fails at least 2 monotherapy trials

Pellock, John, and Michael Privitera. Current Perspectives in Epilepsy Treatment: Focus on Monotherapy. CME Discovery, USA: ArcMesa Educators and Scinexa, LLC., 2006.


Drugs of choice for adults with partial seizure

Drugs of Choice for Adults with Partial Seizure

  • Phenytoin, carbamazepine, and valproateequally effective in the treatment of both generalized and partial seizures

  • Phenytoin

    • Idiosyncratic phenytoin hypersensitivity

    • similar therapeutic and side-effect profile with valproate

  • Carbamazepinepreferred as initial drug because of fewer side effects

Ropper, Allan, and Robert Brown. Adams and Victor's Principles of Neurology. 8th. McGraw-Hill, 2005.


Drug of choice for elderly adults with partial onset seizures

Drug of Choice forElderly Adults with Partial-Onset Seizures

  • ILAE Treatment Guidelines, 2006

    • Based on available efficacy and effectiveness evidence alone, LTG and GBP are established as efficacious or effective as initial monotherapy for elderly adults with newly diagnosed or untreated partial-onset seizures

      (level A)

Glauser, T, ElinorBM, BlaiseBs,et. al. "ILAE Treatment Guidelines: Evidence-based Analysis of Antiepileptic Drug Efficacy and Effectiveness as Initial Monotherapy for Epileptic Seizures and Syndromes." (International League Against Epilepsy) 27, no. 7 (2006): 1094 -1120.


Drug of choice for elderly adults with partial onset seizures1

Drug of Choice for Elderly Adults with Partial-Onset Seizures

  • ILAE Treatment Guidelines, 2006

    • Class I Trial

      • Efficacy: CBZ = LTG and GBP

      • Effectiveness: LTG and GBP>> CBZ


Management

An International Multicenter Randomized Double-Blind Controlled Trial of Lamotrigine and Sustained-Release Carbamazepine in the Treatment of Newly Diagnosed Epilepsy in the Elderly (Satre, Erik, et al., 2007)

  • P: Patients aged 65 years or older, who had experienced at least two unprovoked partial and/or generalized tonic– clonic seizures

  • I: LTG (n = 93) or CBZ (n = 92)

    • 40-week treatment period: initial 4-week dose escalation phase and a 36-week maintenance phase


Management

An International Multicenter Randomized Double-Blind Controlled Trial of Lamotrigine and Sustained-Release Carbamazepine in the Treatment of Newly Diagnosed Epilepsy in the Elderly (Satre, Erik, et al., 2007)

  • O:

    • In the LTG group, 68 patients (73%) completed the 40-week study period compared with 61 (67%) in the CBZ group

    • Higher seizure-free rates for CBZ 46 (75%) than LTG 37 (54%) [OR=0.39, p=0.0129, CI 0.018 to 0.83] in the per-protocol analysis

    • Better tolerability for LTG where 13 patients (14%) withdrew due to AEs in the LTG group, compared with 23 (25%) in the CBZ group

  • M: Randomized Double-Blind Controlled Trial

Saetre, Erik, et al. "An International Multicenter Randomized Double-Blind Controlled Trial of Lamotrigine and Sustained-Release Carbamazepine in the Treatment of Newly Diagnosed Epilepsy in the Elderly." Epilepsia 48.7 (2007): 1292-1302.


Carbamazepine

Carbamazepine

  • Many side effects

  • Leukopenia is common

  • Rare instances of pancytopenia,hyponatremia, and diabetes insipidus as idiosyncratic reactions.

  • CBC should be done before treatment

    • white cell count should be checked regularly

Ropper, Allan, and Robert Brown. Adams and Victor's Principles of Neurology. 8th. McGraw-Hill, 2005.


Lamotrigine

Lamotrigine

  • Lamotrigine

    • closely resembles phenytoin

    • less risk of teratogeniceffects

    • selectively blocks the slow sodium channel  prevent release of glutamate and aspartate

    • effective as a first-line and adjunctive drug for generalized and focal seizure

Ropper, Allan, and Robert Brown. Adams and Victor's Principles of Neurology. 8th. McGraw-Hill, 2005.


Gabapentin

Gabapentin

  • chemically similar to GABA

  • enhances the intrinsic inhibitory system of GABA in the brain

  • anticonvulsant mechanism is not known

  • moderately effective in partial and secondary generalized seizures

  • not metabolized by the liver

Ropper, Allan, and Robert Brown. Adams and Victor's Principles of Neurology. 8th. McGraw-Hill, 2005.


Carbamazepine vs lamotrigine

Carbamazepine vs. Lamotrigine


Post stroke maintenance medications

Post-stroke Maintenance Medications

  • International Stroke Trial (IST, Lancet 1997;349:1569-1581)

    • Aspirin treated patients had slightly fewer deaths at 14 days, significantly fewer recurrent ischemic strokes at 14 days and no excess of hemorrhagic strokes


Post stroke maintenance medications1

Post-stroke Maintenance Medications

Dipyridamole for Preventing Stroke and Other Vascular Events in Patients With Vascular Disease: An Update (Schryver, Algra and Gijn2008)


Discontinuation of anticonvulsants

Discontinuation of Anticonvulsants

  • Studies show that the rate of seizure recurrence after AED withdrawal is about two to three times the rate in patients who continue AEDs

  • ED discontinuation may be considered in patients whose seizures have been completely controlled for a prolonged period

    • 1 to 2 years for children&2 to 5 years for adults

Hixson, John. "Stopping Antiepileptic Drugs." Current Treatment Options in Neurology (Springerlink), 12, no 5 (June 2010): 434-442.


Discontinuation of anticonvulsants1

Discontinuation of Anticonvulsants

  • Factors such known to increase risk of recurrence

    • longer duration of epilepsy

    • an abnormal neurologic examination

    • an abnormal EEG

  • In patients with a favorable prognosis, risk of relapse can be as high as 20% to 25%

  • Before withdrawing AEDs, patients should be counseled about their individual risk for relapse and the potential implications of a recurrent seizure, particularly for safety and driving.


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