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Describe the Pathology, Presentation, Investigation and Management of EpilepsyEdit

ManagementEdit

Test yourself Based on NICE Pathways for Epilepsy

PHARMACOTHERAPY

Pharmacotherapy is individualised according to patient needs. Therapy can be assigned according to seizure type, or by epilepsy syndrome diagnosed.

Other factors include concurrent medication regimes, comorbities, and patient lifestyle and preference.


Table 1: Epilepsy pharmacotherapy based on seizure type
Seizure Type First line therapy Second line notes
Absence Seizures

Ethosuximide


Sodium Valproate

Lamotrigine


Combination therapy

Generalised Tonic-Clonic Seizures Sodium Valproate
Focal Seizures

Carbamazepine


Lamotrigine

Myoclonic Seizures Sodium Valproate
Tonic or Atonic Seizures Sodium Valproate



Table 2: Epilepsy Treatment Based on Syndrome
Epilepsy Syndrome First line Therapy
Benign Epilepsy Syndromes

Carbamazepine


Lamotrigine

Childhood Absence Epilepsy


Juvenile Absence Epilepsy


Other Absence Syndromes

Ethosuximide


Sodium Valproate

Dravet Syndrome a.k.a. Severe Myoclonic Epilepsy of Infancy Refer to Specialist
Epilepsy with Generalised Tonic-Clonic Seizure Only

Lamotrigine


Sodium Valproate

Idiopathic Generalised Epilepsy Sodium Valproate
Infantile Spasms Refer to Specialist
Juvenile Myoclonic Epilepsy Sodium Valproate
Lennox-Gastaut Syndrome

Refer to Specialist


Sodium Valproate

Other, Rare syndromes Refer to Specialist


Special Considerations for PharmacotherapyEdit

Sodium Valproate - Teratogenicity.

Lamotrigine - May exacerbate myoclonic seizures (although it is still a second-line treatment option in syndromes such as juvenile myoclonic epilepsy)

Carbamazepine/Oxcarbazepine - Risk of exacerbating absence or myoclonic seizures.

Pregnancy - offer 5mg of folic acid to all women before pregnancy

Emergency AED therapy for convulsive status epilepticus (published in 2004) Edit

Premonitory stage (pre-hospital)  Diazepam 10−20 mg given rectally, repeated once 15 minutes later if status continues to threaten, or midazolam 10 mg given buccally. 

If seizures continue, treat as below. 

Early status  Lorazepam (intravenous) 0.1 mg/kg (usually a 4 mg bolus, repeated once after 10−20 minutes; rate not critical). 

Give usual AED medication if already on treatment. 

For sustained control or if seizures continue, treat as below. 

Established status  Phenytoin infusion at a dose of 15–18 mg/kg at a rate of 50 mg/minute or fosphenytoin infusion at a dose of 15−20 mg phenytoin equivalents (PE)/kg at a rate of 50–100 mg PE/minute and/or phenobarbital bolus of 10–15 mg/kg at a rate of 100 mg/minute. 
Refractory status a General anaesthesia, with one of: 
  • propofol (1–2 mg/kg bolus, then 

2–10 mg/kg/hour) titrated to effect 

  • midazolam (0.1–0.2 mg/kg bolus, then 0.05–0.5 mg/kg/hour) titrated to effect
  • thiopental sodium (3–5 mg/kg bolus, then 3–5 mg/kg/hour) titrated to effect; after 2–3 days infusion rate needs reduction as fat stores are saturated 
  • anaesthetic continued for 12−24 hours after the last clinical or electrographic seizure, then dose tapered.
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