Treatments   

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Drug therapy, Surgery, Alternative methods

In the treatment of epilepsy, early control of the condition is important as it allows a quicker return to normal lives including playing most sports and prevents any physical harm with recurrent seizures. In addition, early control is associated with successful discontinuation of AED (anti-epileptic drug)/anticonvulsant.

However, treatment is not recommended until the diagnosis is certain because once started, regular long-term medications must be taken which can be taxing (because of the high cost of treatment) and inconvenient (side effects from medications).

There is no harm in delaying treatment provided precautions are taken after the first single unprovoked seizure which relapse rate varies from 30-70%. These precautions include:  

• Stop driving for a period of the next 12 months (minimum)

• Avoids heights

• Avoids swimming or exercising alone but exercise regularly to avoid breathing difficulty.

• Use showers and not baths

• Avoid any precipitating factors (e.g. bright light, alcohol), which are suspected to have induced  previous seizure/s.

• Use relaxation techniques like yoga

• Sleep sufficiently at consistent schedule

• Eat, well balanced and nutritious meals

• Avoiding caffeine, alcohol and artificial sweetener

Drugs Therapy

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Principles

Drugs of Choice

Choice in Young Women

Types of Adverse Reactions

Special Concerns

Drug Withdrawal

Recurrent Risk Factors

Seizure disorders are most often controlled/prevented with medications, which use requires professional consultation for optimum and efficacious outcome. Although they do not cure, they can decrease the number, severity and/or the duration of the seizures and ideally, lead to a seizure-free outcome. Optimal AED therapy may completely control seizures in 60-95% of patients. Seizures still occur while taking  AED.

Optimization of drug therapy is dependent on:

·        Choice of appropriate AED – based upon accurate classification of seizures, common side effects and potential toxicity and their risks in each individual. Considering these factors, trials of several medications may be necessary before the most effective drug is found.

·        Patient’s factors – age, response to AED used, other concurrent medical conditions, medical/medications history etc.

Hence, we can see that drug therapy is all but an individual thing. 

Principles of AED therapy

• An appropriate drug is started with a low dose and if seizure continue and no side effects occur, the does can be increased gradually until seizures are controlled or if there is an overdosed effect. If an adverse effect occur, the dose is reduced to previous tolerable dose and increased with smaller increment.
• Gradual introduction of AED during the first month of the therapy helps to minimize the side effects which frequency will tend to decrease over the first few months as a person's body gain the ability to endure the larger doses of drug used. 
• Such initiation side effects are especially troublesome with carbamazepine, ethosuximide, felbamate, lamotrigine, primidone, tigabine, topiramate and valproic acid. 
• If seizures continue despite maximally tolerated doses, the indication to introduce any add-on drug (of the next first-choice) requires reevaluation of the following factors: 1. Diagnosis  2. Classification of seizure type and/or epilepsy syndrome  3. Presence of an active lesion  4. Adequate dosage (varies widely in individual) and/or duration of the therapy  5. Compliance of the person with the medication schedule (taking AED at specify time is important to maintain the drug in blood at the efficacious level.
• After that, the add-on drug must have its dose gradually increases as described previously. The initial drug/s can be gradually removed if satisfactory control of the seizures is achieved with the add-on drug. Withdrawal of the first drug should be done gradually over 1-3 weeks to avoid triggering any seizure attacks. This is particularly true for phenobarbital and phenytoin.
• This process to achieve monotherapy [use of one single drug in treatment] should be continued until 2 or 3 of the drug of the first choice have failed.
• Only after this, should polytherapy or a combination of 2 or more AED concurrently be considered. Drugs of the same mechanism of action should not be use in a single therapy. [ Combination therapy enhances toxicity and drug interactions may occur between AED. Check this out. ]
• Usually, therapy with a single anticonvulsant is preferred and is effective in 70% of patients.
• If symptoms are not adequtely controlled with 2 drugs but there has been some improvements, a third AED will be added from the newer drugs available.
• If symptoms are not adequately controlled on the two drugs and there is no improvement, the second drug should be withdrew gradually and subsitute with an alternative AED from the newer drugs available. 
• Epilepsy surgery should be considered in people with failed monotherapy with drug of first choice and an initial attempt with polytherapy.
• During therapy, assessing and monitoring for drug/s efficacy, identification of serious side effects and drug toxicity, and evaluation of cause of an unexpected loss of seizure control require: 

1. A record of the seizure with the date and time of occurrence, duration and type to identify any change in seizure frequency, seizure type and the length of seizure free interval. 
2. A record of the AED used including the dosage
3. Monitoring of adverse side effects from blood and/or urine tests.
4. Regular blood level monitoring by a simple blood test. These medications include phenytoin, phenobarbitone and sometimes carbamazepine and sodium valproate.

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