This document discusses the management of epilepsy. It provides an overview of treatment options for epilepsy including antiepileptic drugs (AEDs), surgical management, vagus nerve stimulation, and ketogenic diets. It describes indications for treatment, classifications and side effects of AEDs, management of generalized and partial epilepsies, refractory epilepsy, status epilepticus, and treatments still under investigation.

1. MANAGEMENT OF EPILEPSY DR . ANJANEYULU .SRIRAMA MD;(DM) DEPT . OF NEUROLOGY KING GEORGE HOSPITAL,VIZAG

2. OVERVIEW Indications of treatment of epilepsy Various modalities of management AED’S classification , principles , SE’s,TDM. Management of generalized epilepsy Management of partial epilepsy RE surgical management VNS&KD SE

3. TREATMENT OF EPILEPSY To control seizures with the most appropriate AED without causing any significant side effects. Treatment with AEDs should be started after confirming the diagnosis of epilepsy. Treatment should be initiated following the occurrence of 2 or more unprovoked seizures, after discussion about the risks and benefits .

5. Seizures that may not require treatment Single seizure with unremarkable evaluation Febrile seizures Localization related benign epilepsies in children Benign familial neonatal seizures Simple partial seizures Post traumatic impact seizures Metabolic , Alcohol related, Drug related.

6. Treatment Options 6

7. What Should Be Done During a Seizure? Prevent injury Do not hold or tie the person down Turn the person on the side to prevent aspiration/choking Do not place anything in the person’s mouth Do not pour any liquids in the person’s mouth Do not try to force the teeth apart Stay with the person until the seizure ends Time the seizure Note the type of movement the person is doing

8. 8 Antiepileptic drugs

12. Third Generation AEDS CarisbamateEsclicarbazepine BrivaracetamCarabersat GanaxaloneHuperzine LacosamideLosigamone RemacemideRetigabine RufinamideSafinamide Lacosamide, Rufinamide , Esclicarbazepine and Retigabine have completed phase 2 and phase 3 trails.

13. Step wise approach…… Choose the best suitable drug. If poorly tolerated or fail to improve the seizures choose the alt drug. If the first one greatly improves but not completely. Combine with second drug with complimentary action. If needed 2 to 3 drugs. Withdraw slowly(25% every 4 to 6 wks). Started from a single drug ,Start low and go slow,Monitor regularly.

14. How long AED ? JME ---- life long . SSECT -short term (6 months) AED treatment is as effective as one year treatment. (calcified lesion, might require long term AED). 2 years seizure free period.

15. Evidence and RecommendationsPartial onset seizures

16. Evidence and RecommendationsGeneralized onset seizures

18. FIRST LINE DRUGS Partial epilepsies-CBZ Generalized epilepsies-VPA ADD ON DRUGS Partial-PHB,CLB;/LEV,TPM Generalized-ZNS,LEV,LTG VPA+TPM=hyper ammonaemia LEV+ZNS=SZ++++.

19. Brodie MJ, Schachter SC. Epilepsy, 2nd ed.Oxford, England, Health Press, 2009.

21. Prognostic groups in epilepsy,refractory epilepsy Spontaneous remission (20–30%) - benign epilepsy with centrotemporal spikes or childhood absences. Remission on AEDs (20–30%) - most focal epilepsy and myoclonic juvenile epilepsy syndromes;. Persistent seizures under AEDs (30–40%) .

23. Refractoriness Drug fails to reach the neuronal target (pharmacokinetic hypothesis). Drug fails to act at the neuronal target (pharmacodynamic hypothesis). Seizure phenotype and history of seizures determine the “level of refractoriness” (theinherent disease severity hypothesis).

24. Diagnosis of Refractory Epilepsy Exclude false refractoriness related to - Nonepileptic seizures. (20%) Inadequate AEDs. Noncompliance . Seizure-precipitating factors.

25. EPILEPSY SURGERY RE pts should be referred to specialized epilepsy centers to evaluate the possibility of surgical treatment. Earlier surgery increases chance for persistent seizure freedom . Better quality of life if operated at younger age . surgery should not be delayed.

26. BENEFITS vs RISKS

30. Types of surgical procedures for medically refractoryepilepsy

31. Ketogenic diet Chronic ketosis. GABA synthesis increases. Hyperpolarize neurons and glia.

33. KD –Indian experiance

34. Vagal nerve stimulation

37. STATUS EPILEPTICUS Medical emergency 5% of all epileptic adult clinic patients will have at least one episode of SE in the course of their epilepsy , and in children the proportion is higher (10-25%). Mortality -20%-30% (dying of the underlying condition, rather than the SE itself.) Accounts for 11% in a developing country.(MEENA AK,2000).

38. DEFINITIONS OF SE (nandagopal,post graduate medical journal,2006)

39. Mayo Clin Protocol

41. (1) new AEDs could be used which do not cross the BBB or show systemic toxicity.

42. (2) useful when the epileptogenic zone is near eloquent cortex.

43. (3) prevent noncompliance .

44. Implanting wafers impregnated with chemotherapeutic agents into the resection cavity results in prolongation of survival without an increased incidence of adverse events . Studies in animals have been promising as the application of polymers containing phenytoin to the epileptogenic zone in mice has reduced epileptogenic indexes . Seizure detector coupled with a trigger AED infusion pump has been developed with success in the mouse .

45. Thank you