Epilepsy
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Medpedia on Epilepsy (Less technical, good quality control)
Wikipedia on Epilepsy (Less technical, ? quality control)
Epilepsy is due to abnormal electrical activity within the central nervous system.
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First epileptic fit
The ideal management of a first fit would include completing the special investigations - currently EEG and MRI - on that or the following day so as to decide on treatment and advice respectably soon. A fit commonly places an adult's life on hold, and the balance between not treating those who will prove not to need it, and allowing people to have a second fit while waiting for investigation has not been made well in the UK as yet.
Fitness to drive
According to the DVLA website, Epileptic attacks are the most frequent medical cause of collapse at the wheel.
Diagnosis
- Those with a recent-onset suspected seizure should be seen urgently by a specialist aiming for:
- Precise and early diagnosis to determine:
- Seizure type(s)
- Epilepsy syndrome
- Causes
- Co-morbidities
- Initiation of appropriate therapy
- Precise and early diagnosis to determine:
Treatment
Should be individualised considering:
- Seizure type
- Epilepsy syndrome
- Co-medication
- Co-morbidity
- Individual
- Lifestyle (e.g. ketogenic diet[1])
- Preferences
- Social issues
The SANAD study has provided useful guidance as to likely first choice drugs all other matters being equal for:
Partial epilepsy
Time to monotherapy treatment failure is in the order:[2]
- Lamotrigine
- Oxcarbazepine (not significantly different to Lamotrigine)
- Carbamazepine
- Gabapentin
- Topiramate
- Time to 12- months remission was only significantly worse for Gabapentin, with Carbamazepine, Oxcarbazepine, Lamotrigine and Topiramate having similar efficiencies.
- UK cost benefit analysis at 2006 prices is to the benefit of Carbamazepine by over £1000 per seizure avoided.
Generalised epilepsy
For generalised and unclassifiable epilepsy time to monotherapy failure is in the order: [3]
- Valproate
- Lamotrigine (no significant difference to Valproate]]
- Topiramate
- Valproate was better tolerated than topiramate and is more efficacious than lamotrigine.
- UK cost benefit analysis at 2006 prices is to the benefit of Valproate by £500 per seizure avoided.
Drug withdrawal
In adults monotherapy withdrawal after 2 years seizure free is associated with twice the risk of seizure relapse (15%/annum, 27% after median of 41 months) than continuing therapy at a year and quality of life is not improved by withdrawal. Most withdrawn patients go back on treatment [4].
Pathophysiology
- Usually dysfunction of an oscillatory network
- In some cases mutations in say the SCN1A gene might modulate sodium channel characteristics[5].
- Transition to epileptiform behaviour is secondary to
- Enhanced connectivity
- Enhanced excitatory transmission
- Failure of inhibitory mechanisms
- Changes in intrinsic neuron properties
Interestingly the EEG becomes less chaotic before a seizure suggesting widespread synchronisation
See also
External links
References
- ↑ Ketogenic Diet page, Epilepsy Action. Last viewed October 2008
- ↑ Marson AG, Al-Kharusi AM, Alwaidh M et al. The SANAD study of effectiveness of carbamazepine, gabapentin, lamotrigine, oxcarbazepine, or topiramate for treatment of partial epilepsy: an unblinded randomised controlled trial The Lancet 2007; 369:1000-1015
- ↑ Marson AG, Al-Kharusi AM, Alwaidh M et al. The SANAD study of effectiveness of valproate, lamotrigine, or topiramate for generalised and unclassifiable epilepsy: an unblinded randomised controlled trial The Lancet 2007; 369:1016-1026
- ↑ Lossius MI, Hessen E, Mowinckel P, Stavem K, Erikssen J, Gulbrandsen P, Gjerstad L. Consequences of antiepileptic drug withdrawal: a randomized, double-blind study (Akershus Study). Epilepsia. 2008 Mar; 49(3):455-63.(Link to article – subscription may be required.)
- ↑ Kanai K, Yoshida S, Hirose S, Oguni H, Kuwabara S, Sawai S, Hiraga A, Fukuma G, Iwasa H, Kojima T, Kaneko S. Physico-chemical property changes of amino acid residue accompanied with missense mutations in SCN1A affect the epilepsy phenotype severity. Journal of medical genetics. 2009 Jul 7.(Epub ahead of print) (Link to article – subscription may be required.)
