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Tips for managing people with epilepsy JACOB DAY NEUROLOGY ST5, UNIVERSITY HOSPITALS PLYMOUTH JACOBDAY@NHS.NETWhat this talk is about Epilepsy ◦ An overview ◦ Diagnosis ◦ Management principles (outpatient) Managing common inpatient scenarios ◦ Seizures – in ED, on ward ◦ Nil by mouth ◦ Common antiseizure medicationsWhat this talk is not about Diagnosis of seizures (last week) Outpatient epilepsy management 100s of antiseizure drugs/epilepsy syndromes [Paediatric epilepsy]A few interactive MCQs vevox.app 150-097-253Case 1 64 year old Epilepsy for 20 years, no seizures for 5 years Takes sodium valproate 500mg twice daily Admitted with infective exacerbation of bronchiectasis – treated with IV meropenem. 3 days into admission has several generalised seizures despite taking his usual antiseizure medications. Join: vevox.app ID: 150-097POLL OPEN What would you do to prevent further seizures? 1. Increase dose of sodium valproate 15.38% 2. Add in levetiracetam 20.51% 3. Continue treating the underlying chest infection 10.26% 4. Switch antibiotics 33.33% 5. Call neurology 20.51%Case 2 26 year old lady with epilepsy admitted with acute appendicitis. Takes levetiracetam 750mg twice daily. Vomiting and NBM prior to operation. Join: vevox.app ID: 150-097POLL OPEN What would you do with her antiseizure medications? 1. Switch to intravenous levetiracetam 70.73% 2. Switch to rectal levetiracetam 17.07% 3. Nothing - just restart after her operation 7.32% 4. Give lorazepam instead 4.88%Case 3 19 year old Lennox-Gastaut syndrome, recently transitioned from paediatric to adult services. Takes topiramate, lamotrigine, rufinamide. First admission to adult services with recurrent seizures. again. No response to further lorazepam or phenytoin.am but then seizures start Join: vevox.app ID: 150-097-25POLL OPEN What would the next step (or two) be? 1. Give IV valproate 14.29% 2. Give IV levetiracetam 24.49% 3. Call ICU 40.82% 4. Find the patient's epilepsy care plan 16.33% 5. Give more lorazepam 4.08%What is epilepsy? “a predisposition to recurrent, unprovoked seizures” ◦ Can occur at any age (1/4 develop >60yrs) ◦ ~1% prevalence ◦ ~600,000 people with epilepsy in the UKWhat is epilepsy? ◦ 2 unprovoked seizures > 24 hours apart ◦ 1 unprovoked seizure + >60% chance of having another seizure in 10 years ( abnormal EEG or brain imaging) ◦ EEG can support a diagnosis of epilepsy ◦ Can resolveWhat is epilepsy?What is epilepsy? CAUSES 1. Idiopathic/genetic 2. Secondary to something ◦ Brain tumour ◦ Head injury ◦ Dementia ◦ Cerebrovascular disease ◦ …. What is epilepsy? IMAGE REMOVED FOR COPYRIGHT REASONSWhat is epilepsy? MANAGEMENT PRINCIPLES 1 Treat only if risk of seizures justifies it nd 2 Access to specialist epilepsy team, epilepsy nurse 3 Aim for seizure control on 1 drug only ◦ Choice of medication depends on whether seizures are focal or generalised onset, and others ◦ Build up drugs slowly to mitigate side effects 4 ‘Drug resistant epilepsy’ (no control with 2 antiseizure medications - 1/3 patients) ◦ Can try alternative medications/adding medications ◦ Resective surgery – may be curative ◦ Vagal nerve stimulators – can reduce seizure frequencyCommon inpatient scenarios COMING TO ED WITH A SEIZURE 1 Is it a seizure? ◦ History – from patient and witness ◦ Before ◦ During ◦ After ◦ Look at clinic letters. Ask the patient/family if a ‘usual’ seizure. ◦ Remember that people with epilepsy can still get syncope, dissociative attacks etc.Common inpatient scenarios COMING TO ED WITH A SEIZURE Have they taken their medications? Other triggers – alcohol, sleep deprivation, medically unwell  If a usual seizure type and recovered with a normal examination/bloods/ECG, usually fine for discharge, but please let epilepsy team know.  If concerns regarding medication compliance, drug levels can be considered  Valproate, carbamazepine, phenytoin – easy  Levetiracetam, lamotrigine, others – possible, often take weeks to come backCommon inpatient scenarios ADMITTED FOR ANOTHER REASON BUT HAVING SEIZURES 1 Ensure no ongoing seizures  If prolonged post-ictal state, ongoing confusion, consider non-convulsive status  arrange an EEG 2 Check medications  On correct antiseizure medications and taking them  Look at other medications and check for interactions ◦ Meropenem reduces concentration of valproate ◦ Most antiseizure medications have drug interaction ◦ Some medications reduce seizure threshold in everyone – e.g. ciprofloxacin, levofloxacin, tramadolCommon inpatient scenarios ADMITTED FOR ANOTHER REASON BUT HAVING SEIZURES rd 3 Check epilepsy care plan/clinic letters/family  Usual seizure triggers? Usual frequency of seizures?  Usual strategies to stop seizures th 4 Think about other reasons for seizures (as for anyone without epilepsy ) ◦ Hyponatraemia ◦ Hypoglycaemia ◦ Alcohol withdrawal ◦ Need for CT head, antibiotics etcCommon inpatient scenarios NIL BY MOUTH SO CAN’T TAKE USUAL ANTISEIZURE MEDICATIONS 1 Acknowledge the problem! nd 2 Think of a way to administer usual antiseizure medications (or a suitable alternative) 3 If unsure, ask for help – senior, neurology, pharmacist Common inpatient scenarios NIL BY MOUTH SO CAN’T TAKE USUAL ANTISEIZURE MEDICATIONS Temporary option Direct switch to another route • IV often easiest: levetiracetam, valproate, phenytoin, lacosamide • Orodispersible: lamotrigine, levetiracetam • Rectal: carbamazepine • NG: if absorbing ‘Benzodiazepine bridge’ e.g. IV lorazepam 1mg TDS Caution in elderly Discuss with senior Use alternative IV anti-epileptic Discuss with senior/neurology Some antiseizure medications • Levetiracetam (= Keppra) • Commonly used • PO = IV dose • Can use in status epilepticus • Basically no interactions • 250mg BD  1500mg BD • Can cause mood problems, drowsiness Some antiseizure medications • Sodium valproate • Commonly used • PO = IV dose (give 3 times/day) • Can use in status epilepticus • Lots of formulations • Enzyme inhibitor – lots of interactions • Meropenem significantly reduces valproate level • High risk of congenital malformations Some antiseizure medications • Lamotrigine • Commonly used • Good as an outpatient, a bit tricky for inpatients • Cannot give IV (orodispersible option) • Slowly titrated up • Lots of interactions – esp with other antiseizure medications (valproate, phenytoin, carbamazepine), and COCP Some antiseizure medications • Carbamazepine • Good for focal onset seizures • Cannot give IV (suppositories available) • Lots of interactions – check • Hyponatraemia is common • Rare side effect of agranulocytosis Some antiseizure medications • Phenytoin • Loads of side effects and loads of interactions • Rarely used for as long-term antiseizure medication • Still commonly used for status epilepticus • Can give IV (NB arrythmias and hypotension – need monitoring) • Complicated pharmacokinetics – need trough levels to monitorCase 1 64 year old Epilepsy for 20 years, no seizures for 5 years Takes sodium valproate 500mg twice daily Admitted with infective exacerbation of bronchiectasis – treated with IV meropenem. 3 days into admission has several generalised seizures despite taking his usual antiseizure medications. Join: vevox.app ID: 150-097POLL OPEN What would you do to prevent further seizures? 1. Increase dose of sodium valproate 19.44% 2. Add in levetiracetam 11.11% 3. Continue treating the underlying chest infection 5.56% 4. Switch antibiotics 58.33% 5. Call neurology 5.56%Case 2 26 year old lady with epilepsy admitted with acute appendicitis. Takes levetiracetam 750mg twice daily. Vomiting and NBM prior to operation. Join: vevox.app ID: 150-09POLL OPEN What would you do with her antiseizure medications? 1. Switch to intravenous levetiracetam 97.14% 2. Switch to rectal levetiracetam 0% 3. Nothing - just restart after her operation 2.86% 4. Give lorazepam instead 0%Case 3 19 year old Lennox-Gastaut syndrome, recently transitioned from paediatric to adult services. Takes topiramate, lamotrigine, rufinamide. First admission to adult services with recurrent seizures. Status epilepticus – initially responds to IV lorazepam but then seizures start again. No response to further lorazepam or phenytoin. Join: vevox.app ID: 150-097-2POLL OPEN What would the next step (or two) be? 1. Give IV valproate 10% 2. Give IV levetiracetam 15% 3. Call ICU 45% 4. Find the patient's epilepsy care plan 30% 5. Give more lorazepam 0%Key points 1. Epilepsy is common and variable 2. Patients/families are the experts in their own condition ◦ Clinic letters + epilepsy care plans also helpful 3. Missed medications is most common reason for seizures 4. Think about drug interactions 5. Keep antiseizure medications going at all times ◦ Switch to IV ◦ Use benzodiazepines/alternative antiseizure medications - askFeedback/Questions?