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Epilepsy - Management
What medication needs, use and problems should I assess?
- Assess:
- Seizure control by assessing seizure frequency and severity, and changes in these since the last review.
- For people who have more than one type of seizure, identify how frequently they have each seizure type.
- Encourage people to use a seizure diary to help this assessment.
- The tolerability of drug treatment.
- Ask about compliance and adverse effects of treatment.
- Consider measuring blood levels of antiepileptic drugs if drug toxicity or non-compliance is suspected.
- Refer for review by an epilepsy specialist if:
- Seizure control is poor or unacceptable or drug treatment is poorly tolerated.
- The person has been seizure-free for the last 2 years and would like to consider tapering or withdrawing their treatment. Ensure that they understand:
- The risk and consequences of seizure recurrence following withdrawal of treatment.
- That they are not entitled to drive from the start of the period of withdrawal and for 6 months after stopping treatment, or if seizures recur.
- For further information on driving entitlement, see Medical Standards of Fitness to Drive.
- For people taking antiepileptic drugs:
- Offer lifestyle and dietary advice on how to reduce the risk of osteoporosis. For detailed information on lifestyle advice, see the CKS topic on Osteoporosis - preventing steroid-induced.
- Consider vitamin D supplementation if the person is at increased risk of osteoporosis, osteopenia, and fractures caused by:
- Being immobile for long periods.
- Inadequate exposure to sunlight.
- Inadequate dietary calcium.
- At present there is a lack of evidence or published expert opinion to guide the choice of preparation or dose.
- For women and girls approaching sexual maturity ensure that they are informed about contraception, the risks of antiepileptic drugs during pregnancy, and how to reduce these risks when planning a pregnancy.
- Discuss prescribing folic acid supplements to women of child-bearing potential to reduce the risk of fetal malformation in the event of unplanned pregnancy.
- Discuss specialist referral with women who are taking sodium valproate who are of child-bearing potential, to consider changing treatment to a drug with less risk of fetal malformation in the event of unplanned pregnancy.
- For further information, see the sections on Pregnancy planning and pregnancy and Contraception for women on AEDs, and the CKS topic on Contraception.
- Ensure the same drug brand is prescribed (not generic) when re-authorizing repeat prescriptions.
- Ensure the person is well informed about their treatment and provide written information to support verbal advice.
- See the patient information leaflets on Epilepsy: Anti-epileptic drugs (eruk) and Epilepsy: Anti-epileptic drugs: FAQs (eruk), produced by Epilepsy Research UK, and available through CKS. These leaflets provide advice about:
- Possible adverse effects of treatment.
- When to seek help for problems with treatment or seizure control.
- What to do if medications are missed or likely to be rendered ineffective due to vomiting or diarrhoea.
- Entitlement to free prescriptions.
- Ensure the person understands the importance of compliance with treatment to reduce the risk of seizures and sudden unexpected death in a person with epilepsy.
Clarification / Additional information
- Enzyme-inducing antiepileptic drugs include [NICE, 2004c]:
- Carbamazepine
- Oxcarbazepine
- Phenobarbital
- Phenytoin
- Primidone
- Topiramate
- Adverse effects of antiepileptic drugs include [Epilepsy Action, 2005b]:
- Drowsiness, lethargy, and loss of concentration.
- Aggression or agitation.
- Headache, visual disturbances, tremor, and ataxia.
- Weight gain and weight loss.
- Hair loss and unwanted hair growth.
- Menstrual disturbances.
- Gum swelling.
- Skin rashes.
- For more detailed information about the adverse effects of individual antiepileptic drugs see Appendix G (pdf) of The diagnosis and management of the epilepsies in adults and children in primary and secondary care.
- For full details of adverse effects see the British National Formulary.
Basis for recommendation
- The recommendations to refer for review by an epilepsy specialist when seizure control is unacceptable, drug treatment is poorly tolerated, or withdrawal of treatment is being considered are based on expert opinion [SIGN, 2003; NICE, 2004c].
- These are pragmatic recommendations to ensure that people with difficult-to-manage problems are managed by clinicians with the most expertise.
- The recommendation to consider vitamin D supplementation for people taking any antiepileptic drug at high risk of osteoporosis is extrapolated from recent advice from the Medicines and Healthcare products Regulatory Agency (MHRA) that vitamin D supplementation should be considered in people at high-risk for osteoporosis who receive treatment with primidone, phenytoin, carbamazepine, phenobarbital or sodium valproate [MHRA, 2009].
- A meta-analysis of studies evaluating the effect of antiepileptic drugs on bone mineral density and fracture risk [Vestergaard, 2005] found that:
- Antiepileptic drugs reduce bone mineral density at both the spine (z-score –0.38; p < 0.05) and the hip (z-score –0.56; p < 0.05).
- There was a trend towards antiepileptic drugs increasing fracture risk: pooled relative risk of any fracture whilst taking antiepileptic drugs 2.18, 95% CI 1.94 to 2.45.
- The majority of the data included in this meta-analysis were from people taking the primidone, phenytoin, carbamazepine, phenobarbital or sodium valproate.
- Data from a large case-control study (n = 498,617) included in this meta-analysis [Vestergaard et al, 2004]:
- Found that patients taking carbamazepine, oxcarbazepine, clonazepam, phenobarbital, and sodium valproate were associated with an increased fracture risk.
- Suggested there may be a trend towards an increased risk of fracture for other antiepileptic drugs (ethosuximide, lamotrigine, phenytoin, primidone, tiagabine, topiramate, vigabatrin). However, statistical significance was not reached for these drugs, probably because of the low numbers of people in each group and means this effect is uncertain.
- The recommendation to ensure women and girls approaching sexual maturity are informed about contraception, the risks of antiepileptic drugs during pregnancy, and how to reduce these risks is based on expert opinion [NICE, 2004c].
- The recommendation to ensure that the same drug brand is prescribed when re-authorizing repeat prescriptions is based on expert opinion [NICE, 2004c]. This is because there may be clinically important differences in bioavailability between different brands of the same drug that might affect seizure control.
- The recommendation to ensure that adequate verbal and written advice is provided for people with epilepsy and their carers is based on evidence, considered by the National Institute for Heath and Clinical Excellence, which found that people are often given inadequate information about epilepsy and its treatment [NICE, 2004c].
- A systematic review identified 40 primary research papers published between 1990 and 2000 [Couldridge et al, 2001]. It found that individuals require more information on epilepsy in general, diagnosis, treatment options, medications and their adverse effects, seizures and seizure control, prognosis, injury prevention, psychological issues, social security, driving and insurance, employment, lifestyle, and social issues.
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