Epilepsy Management

exp date isn't null, but text field is

Note: Epilepsy is a medical (neurological) condition – see note in Epilepsy Assessment section. Only start treatment if no medical or paediatric service is available.

 

  • Look for treatable causes (infections, tumour, alcohol).
  • If patient has more than two afebrile seizures on different days in a year, consider starting antiepileptic therapy.
  • Always start with a small dose, increase gradually over weeks or months and use maximum dose of one drug before adding another
  • Treatment should never be stopped suddenly due to risk of status epilepticus, taper over weeks or months
  • If patient is a woman in the second half of pregnancy or recently given birth, suspect eclampsia and refer urgently.
  • Any prolonged seizures or repeated seizures without recovery of consciousness in between (>30 minutes) is Status Epilepticus - a medical emergency and mortality is high. For emergency management of a seizure – see separate management chart in Part 2

 

Physical Exam and Investigations

  • Always do a physical exam to look for reversible cause e.g. infection, alcohol
  • FBC, U&E, glucose, VDRL + MRDT, consider HIV test, urine drug screen if appropriate.
  • Assess for comorbid mental health conditions, higher rates of depression and suicide in those with epilepsy

Psychosocial

Epilepsy often has a considerable impact on the psychosocial wellbeing of patients

  • Use information leaflets for patients and carers to reduce anxiety
  • Adherence to medication is crucial
  • Encourage a positive self-image
  • Minimize time off school or work
  • Maintaining a good diet, getting plenty of sleep and avoiding illegal drugs and alcohol decrease seizure frequency

Medication

Convulsive seizures in children

  • Sodium Valproate 20-40mg/kg/day in 2 to 3 divided doses       

Alternatively

  • Phenobarbitone 5-8mg/kg nocte       

Or

  • Carbamazepine 2.5mg/kg bd and increase weekly by 5mg/kg until 20mg/kg is reached

Non-convulsive seizures in children

  • Carbamazepine 2.5mg/kg/day bd

Alternatively

  • Sodium Valproate 20-40mg/kg/day in 2 to 3 divided doses

Epilepsy treatment in Adults

  • Phenobarbitone 60-180mg nocte

Alternatively

  • Carbamazepine 200mg 1-2 times daily. Increase by 100-200mg weekly until dose is 800-1200mg per day

Or

  • Sodium Valproate 600mg daily divided doses. Can be titrated up to 2000mg daily in two divided doses

Or

  • Phenytoin 150-300mg daily in 1-2 doses.

Red Flags

  • Avoid sodium valproate in women of childbearing age if at all possible.
  • Avoid polytherapy in pregnant women.
  • Carbamazepine preferred if breastfeeding.
  • Sodium valproate is preferred in people with HIV due to fewer drug interactions; avoid phenytoin and carbamazepine in HIV where possible.

Referral, Admission and Follow-Up

Referral

  • Increasing frequency or duration of seizures despite medication

Admission

  • Status Epilepticus; suspected eclampsia

Follow-Up

  • Reviewing the patient once a week until seizure management improving
  • Assess risk for side effects, depression and suicide at every review
  • Only consider stopping treatment if two years without seizures, reduce over month