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Management of epilepsy
Questions from healthcare professionals
Q: Has there been any research into the relationship between constipation and epilepsy? For example, does severe constipation trigger seizures?
A: you can find a previous answer to this question below. You might also like to look for research studies on the PubMed website at: http://www.ncbi.nlm.nih.gov/pubmed
Q: Where can I find articles on SUDEP (sudden unexpected death in epilepsy)?
A: There is a chapter from 'Epilepsy 2009' on SUDEP, which you can access through 'articles' on the professional section of this website under 'outcome'. You can also access articles through the PubMed website (http://www.ncbi.nlm.nih.gov/pubmed) by searching on 'SUDEP'.
March 2011
Q: I am a pharmacy student doing a project on how to set up a Therapeutic Drug Monitoring (TDM) service in secondary care. What is the procedure for TDM, and what equipment and personnel is required? How much does each test cost?
A: You can find out more about our TDM service here: http://www.epilepsysociety.org.uk/WhatWeDo/Treatmentandfacilities/Therapeuticdrugmonitoring There are many different types of TDM so the answer really depends on the type of service you are investigating. You may find that you can get the best help by getting in touch with your local hospital TDM service.
Answered by Epilepsy Society's Pharmacology service
February 2011
Q: What should an epilepsy review involve? Who should carry this out? Is it appropriate for parts of this review to be carried out over the telephone by a healthcare assistant?
A: The National Institute for Health and Clinical Excellence (NICE) has a Clinical Guideline on the treatment and management of epilepsy, and this covers best practice in terms of epilepsy reviews. You can access the full guideline here: http://www.nice.org.uk/nicemedia/live/10954/29533/29533.pdf
January 2011
Q: What is the likelihood of post-ictal psychosis returning once an individual is started on antipsychotic medication?
A: We would expect that the chances are reduced by the use of anti-psychotic medication, if it is taken consistently. However, it would not be possible to rule out the chances of it happening. We are not aware of any controlled trails on this subject.
November 2010
Q:Is there a link between epileptic seizures and constipation. I have read anecdotal accounts of fitting-like episodes or events around toileting, and the use of laxatives as a preventive measure.
A: For some individuals, gastric problems, including constipation, can be a side effect of some anti-epileptic drugs. There may also be links because:
- Constipation can cause pain or discomfort, which can raise stress or anxiety levels. This, in turn, can affect seizure control.
- Constipation could affect the absorption of the medication, and thus affect seizure control.
- If laxatives affect the individual's appetite this may result in them not eating or drinking enough, which could affect seizure control.
With respect to management options, an overall picture of the situation, including looking at diet and exercise, can be helpful in identifying options for treatment. In addition, some individuals may have idiosyncratic responses to laxatives.
February 2008
Q: In a patient diagnosed with myoglobinuric renal failure how is their epilepsy best treated?
A: Myoglobinuric renal failure is a very rare complication of status epilepticus or serial seizures. We would not be able to comment on a treatment strategy for such a individual.
September 2008
Q: What is the prognosis for occipital partial seizures? Are there guidelines for continuing drug treatment when seizures are reduced by 90%?
A: There is no major difference in terms of prognosis from epilepsy arising in the occipital lobes and epilepsy arising from other sites or lobes. Guidelines for drug treatment would be the same as for all partial seizures. You can find several papers on drug treatment of epilepsy within the Medical treatment of epilepsy section of the Library of Articles on this website.
April 2008
Q: What are the drug options for the management of cluster seizures?
A: One option for the management of seizures clusters is the use of clobazam. For more information on this drug please look at the paper Overview of established antiepileptic drugs under the Library of Articles.
February 2008
Q: Is it safe to treat patients who are alcoholics for seizures relating to this or are you putting them more at risk as they are not usually concordant to treatment anyway?
A: It depends on the clinical situation but treatment is usually contraindicated if the person is not concordant to treatment.
November 2007
Q: Re: Temporal lobectomy for epilepsy 1. Approximately how many performed per year in UK 2. Approximately how many centres in UK perform this procedure? 3. What criteria is used to judge whether epilepsy severe enough to proceed to surgery?
A: Exact figures not known but probably less than 300 per year. As far as we are aware, there are currently, 3 centres that do more than 25 procedures per year and another 6 – 8 centres that do less than 25 procedures per year. The criteria needs to be judged in each individual case but usually at least 2 partial seizures a month and having failed treatment with 2 – 3 AEDs.
November 2007
Q: Is there any evidence to suggest that epilepsy caused by a trauma to the brain, (in particular, intrathecal Methotrexate), is more difficult to manage?
A: We are not aware of this being the case.
September 2007
Q: What is the best treatment/response for a child who has been found to have a level of 37mg/l of Phenytoin and indicators of toxicity?
A: This is a high level of phenytoin and if there is evidence of toxicity, dose reduction should be considered, with careful consideration of possible effects on seizure control.
September 2007
Q: Of all the available AEDs, which drug would be most suitable for treating generalised seizures where liver function is impaired?
A: AEDs need to be used with caution where liver function is impaired. Drugs should be chosen according to clinical need, however if possible avoid using valproate. All drugs apart from gabapentin and pregabalin will need dose adjustment in people with liver failure.
August 2007
Q: Does dysrrhythmic EEG background affect the choice of anti-epileptic drug to be chosen in focal or generalized epilepsy?
A: No.
March 2007
Q: Should AED dose be increased in patients with transient epileptic amnesia if seizure frequency has decreased but they are still complaining of poor recall of information?
A: In transient epileptic amnesia (TEA) the main feature of the seizure is an impairment of the ability to retain new information. Many of these patients also perform poorly on memory tests and complain of everyday memory difficulties between seizures. Patients with TEA often show evidence of temporal lobe disturbance in EEG or MRI. Underlying pathophysiology in the temporal regions that underlies the amnestic seizures would be expected to give rise to ongoing problems forming new memories. The nature and extent of the problems will depend on the extent and location of the abnormalities in the temporal structures. Increasing medication will not be expected to improve memory and could have adverse effects due to impaired concentration.
December 2006
Q: My patient was taking one AED but was not seizure free. The consultant has added a second AED and asked the patient to experiment with doses. Is there a methodical recommended approach?
A: In most situations the consultant would give clear guidance on how to increase the dose when starting a new drug. The British National Formulary and Mimms – Guide to Epilepsy both have guidelines for titration of AEDs. Seizure frequency and side effects being experienced would need to be take into account in this process.
November 2006
Q: What is the drug of choice in mesial temporal lobe sclerosis?
A: Treatment for mesial temporal lobe sclerosis is as for partial epilepsy – see the Library of articles on this website.
July 2006
Q: At what rate should phenobarbitone be withdrawn in a young child if a switch is being made to another anti-epileptic drug?
A: Phenobarbitone should be withdrawn over a period of four months. There is a risk of withdrawal seizures, however if a child is starting alternative medication this risk should be minimal.
July 2005
Q: Are there any precautions that should be taken regarding anticonvulsant treatment when a person has survived Reyes Syndrome in childhood and has epilepsy?
A: There are no precautions that we’re aware of.
May 2005
Q: Why are bromides not used anymore to treat epilepsy?
A: They aren’t used because they are associated with too many side effects.
May 2005
Q: If a patient is first treated with oxcarbazepine and develops a rash, is the drug to be withdrawn or the dose decreased and re-introduced slowly?
A: It is better not to re-introduce the drug. The drug should be withdrawn and an alternative given.
December 2004
Q: What are the consequences of being outside the blood target range for patients on phenytoin? What actions should be taken for such persons?
A: This depends on individual circumstances. It is best to speak to the person's attending physician regarding this.
September 2004
Q: Does delay in controlling seizures result in more frequent seizures and more resistant epileptic disorder?
A: There is no evidence that delay in controlling seizures results in chronicity.
August 2004
Q: Is acetazolamide used in the treatment of epilepsy?
A: Acetazolamide is a second line drug. It is effective against generalised tonic-clonic seizures, partial seizures and atypical absences. It may also be used to treat menstrual related seizures and certain episodic disorders, and to enhance other anti-epileptic drugs such as carbamazepine.
August 2004
Q: In older children – between five and 12 years old - who have photosensitive seizures induced by one specific activity, would it be reasonable to defer medication and just try avoiding the activity in question?
A: This is not unreasonable, providing it is pure photosensitive epilepsy - not part of idiopathic generalised epilepsy or another epilepsy syndrome. It would need full discussion with the family.
August 2004
Q: Is it contra-indicated to add phenytoin to carbamazepine in a patient not responding to the latter alone?
A: There is no contraindication to add phenytoin to carbamazepine. Please see the information in Library of articles – Medical treatment of epilepsy – The management of chronic epilepsy.
July 2004
Q: Is sodium valproate/valproic acid combination more effective than valproic acid alone as an anti-epileptic?
A: The end product is the same for both sodium valproate and valproic acid. There is no evidence than a combination is better than one or the other.
July 2004
Q: Is a combination of valproate and lamotrigine more effective against partial seizures than carbamazepine?
A: People with epilepsy have different responses to anti-epileptic drugs. Monotherapy is preferable to polytherapy; when starting treatment only one drug should be used. For more information see the articles in Library of articles – Medical treatment of epilepsy.
May 2004
Q: Is carbamazepine more effective against partial seizures than valproate?
A: Carbamazepine and valproate are both first line drugs used to treat partial seizures. Drugs are usually chosen according to seizure type, however other factors may need to be taken into consideration. People will show individual responses to anti-epileptic drugs. For more information see the articles in Library of articles – Medical treatment of epilepsy.
May 2004
Q: Which anti-epileptic drug is best used in symptomatic epilepsy arising as a complication of chronic renal failure? Which ones are best to avoid?
A: Treatment will be the same as for epileptic seizures arising as a result of other causes. However the dose of anti-epileptic drugs that are renally excreted should be adjusted accordingly. For more information see the articles in Library of Articles - Medical treatment of epilepsy.
April 2004
Q: Is it correct that in juvenile myoclonic epilepsy (JME) it is easier to control the tonic clonic seizures than the myoclonic seizures?
A: No, this is not correct. Most cases of JME have complete resolution of both myoclonic and generalised tonic clonic seizures with the same drugs and often with the same doses.
April 2004
Q: Given the fact that tegretol aggravates myoclonus, is it contra-indicated in juvenile myoclonic epilepsy in combination with valproate?
A: Yes it is contra-indicated in JME.
February 2004
Q: Does lamotrigine aggravate myoclonus?
A: Lamotrigine may aggravate severe myoclonic epilepsy of infancy, a relatively rare form of myoclonic epilepsy.
February 2004
Q: Is there another method of giving the loading dose of epanutin other than than the intra-venous route?
A: Phenytoin can be loaded by mouth, however this cannot be done in status epilepticus.
February 2004
Q: How should I manage stroke patients who have had a first seizure after the stroke?
A: Treatment of seizures after stroke is the same as for other partial seizures. There is information about management of a single seizure on this website in Library of articles - Medical treatment of epilepsy - Starting antiepileptic drug treatment.
January 2004
Please note: Epilepsy Society is unable to provide a medical opinion on specific cases. Responses contain information relating to the general principles of investigation and management. Answers are not, and should not be assumed to be, direct medical advice.
