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right. So I'm Jacob. I'm a neurology road. A stronger STP five working in southwest of England. Currently working. Promise. I don't know how many of you were here last week when I did a similar type of session focused on the actual diagnosis of a seizure and the differential diagnosis off that Now I'm going to do a talk kind of fixing warn people with with an established diagnosis about Let's see. So for those of you who were there last week, you might get a little bit of deja vu about the structure. But hopefully it worked. Okay? Last week. Um, so what this talk is about, I basically want to give you an overview of epilepsy. Obviously epilepsies a pretty massive topics. I'm not going to get into a lot the details, but just to kind of really headlines about about epilepsies of the terms we use. But how we diagnose it on then a bit about the management principals which I think are quite quite useful just for understanding out of the range rep lips And what what we try to do in neurology in our patients, uh, in the second section, which I hope is gonna be the bit. That's kind of really kind of practically helpful for you is about kind of managing common in patients scenarios. So the ones are planning on fixing on. Ah, what kind of keep oint for people with epilepsy who presents to the hospital because of the seizure on, then people with epilepsy hurry hospital, foot, foot something unrelated. So another reason, but then have a seizure while they're in hospital. We're also going to talk about kind of things we can do regarding anti seizure medication, people who can't take them, the LEEP 60 people who have no by mouth on. Then I'm just going to do a few kind of key points about some of the common anti seizure medications that you come across. What this dog is not about not about how to diagnose a seizure, which was last week. It's not really about outpaced net but outpatient, uplifting management, or that I am going to give her just a one slide. A preview of that's I'm not going to talk about low to No. Two drugs or complex epilepsy syndromes. Don't worry on. It's not really about pediatric epilepsy. Just because I'm working adult urology, or I think a lot of the principals would apply to pediatric epilepsy as well. Okay, so again, I'd like to start off with just a few interactive multiple choice questions to check those people out there listening and just to get you thinking. So if you're able to get your phones or computers out and go to the box stop until I have been that session, I d, um, be also give live responses to a few of them. Stick use that coming. So I'll just give you a minute to do that. So you know there's not really right or wrong answers to these is just to get you thinking. Then we'll do the bulk of the talk, and I will have the same questions at the end to see if people have changed their minds. Okay, so the session idea does come up when natural questions come up. So if you haven't had a chance, don't worry. But hopefully, most of you have so cases 64 year old man. This is someone who's had epilepsy for a long time. 20 years on is really well controlled. There's not anything. There is a tool for five years, which is pretty. He takes a kind of middling dose of sodium valve great twice a day, and he's an impatient on the respiratory. What he's also got bronchiectasis. He's got quite a bad effect of exacerbation because it's bronchiectasis. He's got some funny bugs, so he needs to be on pretty heavy duty. Antibiotics would be meropenem few days into it into his admission. He has a few seizures. That's really unusual for him on he's been taking his usual seven about rate during the admission. So what would you do to prevent further seizures in this situation? If you're on call and you've been caught, this person, he's had a few seizures. He's fully recovered. There's no concerns about that. What do you think you're due again? No. Right or wrong answer. Just just to say what your gut feeling is. Okay, see what we're looking that Okay, But if it's not something, I think that's probably fair enough. So some of you Yeah, So somebody increase the dosage operate. Some would add in something new. Some people would say, Well, it's just the infection causing it. So keep treating that someone switched antibiotics and some one called help. Fine. Okay. Case, too. 26 year old lady again Has epilepsy take Aleve a trusted time. 750 mg twice a day. And she's in hospital because I'll be cute. Appendicitis. So again, something completely unrelated. She's quite well, She's more missing. She can't eat. And she's actually near by mouth anyway because we're planning Teo trying to have an operation tomorrow. So what are we going to do with her anti seizure medication? We're going to switch her Teo IV level. Trust the town. We're going to switch her to rectal. Ever trusted. Um, we're just gonna wait until her operation is done. Hopefully, tomorrow and then Exception. Gonna miss a few days is what we're going to give us something different entirely. Like the Razadyne. Yeah. Okay. So most people want to try. Maybe another trust him. Sounds fair enough to me. Okay, last one. It's a 19 year old girl. This is someone. This is a This is a really one that stuck in my mind from quite recently. So she has kind of like a complex pediatric epilepsy syndrome called Lennox Gastaut. And she's had a lot of hair under the pediatric epilepsy team and being out of a lot. But as always happens, she's now transitioned to adult services, which is an entirely different team. Different any different epilepsy nurses? Consultants never think she's on a few different anti epileptics on board. The first time she needs to get an emergency admission to the adult service is is with a cluster of really bad seizures, so recurrent seizures one after another. Basic. She's in status epilepticus. She gets my being a resident, Um, as per protocol on Day settles initially, but then they start up again. She gets the more lorazepam, and then since then it's very but she's still seizing except before he would be doing this by yourself. But what do you think the next best step might be on? It is definitely more than one option to consider here, so we could give a couple more IV's for the status either IV Valparaiso. I roll ever traffic jam, call intensive care, see if they would do a general anesthetic to control the seizures. We could try and find her care plan and see if anything differently could be done in this situation. We could give us a more benzodiazepine. Okay, again. A bit of a mixture, but most people gain for colitis. You, which again, I think, is very fair enough. OK, so Okay, so that's just to get you thinking So, um now first of information and we'll revisit those at the end. So very kind of broad, you know, keep oint. What is that? Let's see. The epilepsy is just a credence position to recurrent unprovoked seizures. That's all it is. It just means that people that someone with that let's see someone who can have seizures out of the blue for no particular reason. It's pretty common. It's about one in 100 people, which equals roughly 600,000 people in the UK, and it can occur in any age. You know, we tend to think of epilepsy kind of more of that kind of childhood and young adult hood thing, but really it can happen in any agent. Actually, the most common time to have a new diagnosis of epilepsy now is in later life, and over a quarter of people get epilepsy after the age of 60. In terms of diagnosis or more clinical diagnosis, we would say that anyone who has to unprovoked seizures more than 24 hours apart. That's enough to say that someone has epilepsy, so you have to be actually clear that it's an unprovoked seizure. And if you have a few a winning one kind of 24 episodes that, then we would just class that as kind of one episode. So that's why the 24 hours is there. You can't have a diagnosis of epilepsy after one on provoked seizure if you're proven to be a higher risk than average of having more so after one unprovoked seizure free, generally say we've got about a 50% chance of having another one in the next 10 years. But if we can show with some investigations that actually you're a higher risk than average. So typically this is if we do, uh, any GI and shows, um, epileptic features or some brain imaging and show something structural that might be causing seizures like some developmental scarring or brain Schumer. Then that's gonna put you generally above a 60% chance of having another seizure. And that's the current accepted kind of definition epilepsy, so any GI can support a diagnosis of epilepsy, but you need a clinical diagnosis of seizures to make the diagnosis. And they're certainly lots of people with epilepsy who have a normal EKG. Epilepsy can resolve as well, so that typically epilepsy, child's and childhood epilepsy syndromes people can grow out off, but also some adult onset epilepsies. If you're seizure three for between 5 to 10 years off medications than, say that it's resolved. So it's not always a lifelong diagnosis. Okay, just briefly pointer up. This is the kind of most recent classifications seizure type. It is a little bit complicated, but basically what focal on sets, Then you got generalized onset. Um uh, on this has changed. The might have heard the term partial seizures that that is now a focal focal onset seizure. I think it was more kind of acceptable to patients with with focal seizures, because partial makes it sound like it's maybe not as bad. Um, on the kind of term kind of secondary generalization, we have a focal onset and then get a generalized seizure that's been replaced like focal onset focal toe bilateral tonic, clonic. There's just a slight change in terminology that came about in 2017. You hear kind of a low times used in general. But these are the most up to date ones. Okay, a focal onset. You can be fully aware when you can have impaired awareness on. Then there's ulcer sorts of different epilepsy. Other seizure types. So, um, let's see you get your kind of typical generalized onset tonic clonic six. Um, you can get focal on, sir, um uh, chronic six. But then there's a whole list of other things your autonomic features behavior arrest. You could get hyperkinetic seizures. So if anyone's read Suzanne Somers been spoke. She describes, uh, one of her patients with epilepsy. When they get a seizure, just starts running, it just runs and runs. So when it happens, everyone has to be aware to gonna lock the doors. That doesn't run out on the road. So you can get really quite unusual seizure times, but we won't run on the details of that. But that's just to make you aware of the most up to date a classification of seizures, um, and then leaving on. Sure. Um okay, Well, okay. So in terms of causes, we could say that epilepsy is kind of it can just be one of those things and idiopathic, we don't have a definite cause. It's just something that someone develops. We don't find one absolute course for the epilepsy. It's probably genetic, but it's probably a contribution of lots of different genes rather than just a single gene allergy. MM, Or epilepsy can be secondary to something so often. It's something structural, like a brain tumor or head injury. Cerebrovascular disease and strokes is really common, so that's often why patients who are more elderly develop Pepcid epilepsy as well as dementia. Also, other things like previous infections like a viral and capital itis, those things can all be a cause of epilepsy. This is a slight I thought was coming in next with the last time. So we kind of you define a seizure type as on that last slide. And then you use that to describe the type of epilepsy you can sometimes given exact cause, particularly structural, sometimes infections. Sometimes it's a single gene cause, but often we don't know, and it and in some cases we can define the top of that. Let's see syndrome. So that's kind of how epilepsy is described Unclassified. Okay, so one slide about the really important management principals off people with epilepsy. So first, as with anything in medicine, really, you should only offer someone treatment if the risk off that condition justifies it. Okay, so anti seizure medications have loads of side effects, so that has to be a high enough risk of seizures without medications. In order to justify that, everyone with epilepsy should have access to a specialist team and particularly an access to anaplastic new a specialist in addition to the medical team in terms of drug controlled drug use. So obviously, our main arm for treating epilepsy is with medications, and what we'd always aimed to do is to try and get people completely controlled on a single drug. Okay, single anti seizure medication. Exactly what medication we choose would depend on a lot of things, but in particular whether it's focal, generalized onset and then other people's came abilities gender to some extent where the people who get pregnant or not on our people have gone with previous medications in side effects in terms of side effects, and often see that you know people will build up antiseizure medications quite slowly. On the idea of that is that it just reduces the side effects. Okay, make people tolerate them better. So all anti seizure medications will make people feel a bit tired. Dizzy fatigues drowsy sometimes because they're all actually just dampening down the signaling. At the end of the day, if we if you go in there are high kind of treatment dose straightaway, those side effects could be really debilitating. And then people just stop taking the medications. So the idea of building up slowly is just a just a improved tolerance of the medication. And obviously, if you're weaning someone off medications, you also do that study because you don't want to have the risk of rebounds. Usual our aim. And I hope when someone is diagnosed with that, let's see is you get on my kind of lowish dose of the medication with no side effects, and they're completely controlled. And that's the idea. There are plenty of people that let's see, like that's okay, but of course, the people where that is not good enough. And there's this concept of drug resistant epilepsy, which basically it just means that you've tried good doses off to appropriate antiseizure medications and just still not free of seizures. And that effects rush me. One in three patients, people with epilepsy. So it's a reasonable proportion. Okay, in terms of what we do, then there's always the option of trying different medications. There is a long list of anti seizure medication that can be tried, but we don't have great ways of predicting exactly who will who will respond to which ones and you can add in medications that I'm sure you know, people are often are multiple anti seizure medications. But the problem is that by the time you haven't responded appropriately to two anti seizure medications, the chances they're going to respond to a third and the fourth just get lower and lower. It's the kind of law of diminishing returns on zero with allergy in side effects with medications with more medications receptive, surgery can sometimes be a curative option. People with drug resistant epilepsy, particularly where it's where it's focal on setting. It's due to something like a scarring or developmental abnormality in one part of the brain. So that's something that's done in kind of specialist epilepsy centers, which you might come across a bit. I was just gonna mention vagal nerve stimulator is there is another kind of surgical option for people with drug resistant epilepsy. This is not the same a surgery because it doesn't cure people off. It doesn't ever need to complete seizure control, but it can have a really valuable reduction in seizure frequency on. But there's lots of kind of new things coming with them now, or new issues. So some of them are able to sense heart rates of the heart rate's going up, and they think that might suggest that kind of an early seizure. Then the stimulation could increase to try and stop it developing and took from seizure on. Patients with them can also have a magnet. Whether you've got a boost, the signals if they show if they have a cluster of seizures or something like that. Okay, so that's, um, that's my overview of epilepsy, and now we're going to move on to some common impatient scenarios. So the first one is someone with a diagnosis of epilepsy who's presenting dolls so normally, the Emergency Department, because all the seizure So what are we gonna do first? Things like last week we're going to say, you know, is this episode of run responsiveness of jerking off confusion, whatever it is easy to actually a seizure again, always has to be the first question. They were someone with epilepsy. Your OB was gonna think it's more likely to be a fusion and someone without so you're starting off from that position. But you shouldn't ever miss You. Always take the history from the patient on a witness of what happened before, during and after the event, and then with someone with epilepsy, you want to do more information gathering. Do you want to know what their electric, what their seizure types of like normally? Because that's really valuable information for you to try and work out whether this is one of their usual types of seizures or if it's something different altogether. So the things you could look out clinic letters okay, they they should describe someone seizure frequency, someone seizure on diaper. And you can also cause asked the patient on the family, because at the end of the day they are the experts in their chronic condition. They will almost always be able to say this is a normal type of seizure or if it's unusual if someone says Yes, I have epilepsy, but it's really well controlled. And what happened today was absolutely nothing like my normal seizures. Then you really need to think harder. This is something different, okay? And on those lines, just always remember that people with epilepsy can still get other things. Okay, they could still get syncope. They can still get disassociative attacks. You don't want to miss some with a dangerous arrhythmia calls in a defeat, just putting it down to their usual. If you think it is a seizure, then the next question is, Have they been taking their medications? Have they missed any accidentally? Because the most common reason for someone with epilepsy to have a seizure is because I haven't taken the medications that's planned. Okay, think about other triggers as well. They alcohol, sleep deprivation if they're unwell. A thing on infection if they got no sody in anything like that that can cause anyone to have a seizure is obviously going to be more likely to cause someone with epilepsy to have a seizure is well. So if someone with epilepsy has had a normal normal one of their seizures, that's not unusual for them. they're fully recovered. You've done a full history. You've done an examination which is normal. You've done the bloods with the electrolytes and blood sugars, and you've done an EKG, and that's all okay. And those people generally can go home if they do them. Please remember to let the epilepsy team no email the epilepsy nurse. Let the red strong call know You can often ask the patient on their family to do that, but I think to be on the safe side, you should probably do it yourself. And then you know that it's been done then then they could be plugged in for early follow up or a telephone call or something. You know that then that they're kind of chronic disease is being managed in the oxygen way. You don't have to make the decisions about that, but But if we don't know that someone has been in them, then we can't make any changes. Based on that, it's just going to mention something about one of drug levels. Um, so, you know, one of the most useful. One of the main reasons that we would do anti convulsant drug level blood levels would be to see whether someone has definitely taking their medications or not. So I guess if there's any kind of uncertainty of the patient saying they did take them. But they're partners saying that they think they have mean it could be really helpful just to get off one off on anti convulsants level on their admission. Bloods, um, things that are easy to do. So about parade carbamazepine finito and they're all pretty routinely done. I think pretty much all hospitals do that and have a pretty quick turnaround. Okay, all that anti convulsants can be measured. The concentrations can be measured, so definitely Levitra System and the mantra gene on several others. But they often have to be sent off to a different laboratories, and they sometimes take many weeks to come back. There's not going to change what you do there and then, but if you think it's an option, then I would certainly consider sending that. You're not sure? Just ask. Okay, so, 2nd, 2nd scenario, this is someone with epilepsy. He was in hospital workers there unwell for something entirely unrelated to the epilepsy. But while they're in the hospital, they're having seizures. Okay, so what's our focus going to be there? Well, first, we need to make sure you don't have any ongoing sieges. Obviously that that is the case for someone coming to go to the department. First and foremost, I think it's a little bit harder in someone who's on. Well, for another reason is maybe you've been admitted for over a week or something, because often someone could have a kind of obvious type convulsive seizure on, then just remain drowsy and just be confused for a long time afterwards. And that might actually be little seizures that are ongoing, that I'm not obvious but keeping them in that on, well, states. So if there's any sense of a kind of a really prolonged postictal state that are ongoing confusion, delirium and think about whether they're having ongoing seizures and think about in particular whether they're non convulsive status, Epilepticus, which is not as much of an emergency, is combos of status epilepticus. But it is absolutely something that needs to be diagnosed and treated. The two options for diagnosing it well, basically trying to EDG that would depend on your availability. Okay, but, you know, I think certainly drink working hours most places will be able to get any GI. If you really can't get any GI, then you're gonna have to think about whether you just need to give them empirical treatments or something like IV there as a Pam, but definitely discuss that first cause, you know, cause you're spiritually depression is going to need to be somewhere reasonably high observation, high visibility. So someone with epilepsy having seizures admitted to something else, make sure they're not having any ongoing seizures. The next thing we're going to do, you're seeing a bit of a theme here. We're gonna check the medications, okay? We need to know, Are they on the right medications that they normally take? And are they taking them? Okay, you know, as with anything chronic, you know, epilepsy, Parkinson's, COPD, asthma, whatever it is when someone comes in, two doses of the last thing we want to do is make things worse by not giving them the regular medications, disrupting that chronic condition. Okay, and it's pretty common with that. Let's see, you know, sometimes it's confusion about the doses because people might be the middle of going up or down on dose is some plans are also slightly unusual. Medications are not so available. Actually ordered from pharmacy. Take. You know who knows how long? Sometimes and sometimes people around well, and they're not able to swallow the tablets that they're they're normally on. You need to make sure that prescribes. Make sure that doses of correct on that they've actually being receiving them. And if they're not, we need to do things to correct that. Pretty sharpish. Okay, look at other medications as well. Okay, and check for interactions. So I'm sure, you know, on two seizure medications interact with lots of other medications. That might be something we've given them, like an antibiotic or something else that's disrupted the steady state concentration. And that might be a reason why they're having seizures. So if you just to look out for the Mirapex, um, reduces the concentration of operate a lot at least kind of to thirds is a really significant reduction. Um, if in doubt, just check, you know, pretty much a low the antiseizure. Pretty much all the older anti seizure medications have some kind of drug interactions is quite hard to remember the border. So if you're not sure, just going to be an f you know, free online webpage free online app on Just tap it in and remember that some medications reduce seizure threshold in everyone's not just people that would, actually, although they're going to be the ones who are already more prone to a reduction in seizure threshold. Present seizure threshold is already lower than average on some common ones would be through a quinolone antibiotics and also pills and particularly tramadols. If you see those and someone having seizures, then we need to think pretty carefully about giving them something difference. Okay, so after the medications, um, well, then you need to look at their epilepsy care plan or clinic letters, or talks the family about how their epilepsy is normal and how it's managed normally. So particularly like it's a really useful clues are the usual seizure triggers on the fate of sensitive in their sat next to a window with the tree kind of, you know, going into branches kind of flicking through the sunlight. We just need to put the curtains and read them away from the away from the window. What's the usual frequency of seizures? You know, some people with drug resistant epilepsy have lots of seizures. Okay. And unfortunately, that is kind of that their baseline is there. Some people might have a seizure every day or every couple of days. So if that's what's happening else, so we don't need to go doing lots of things to try and change that. Okay, um, some of them, some epilepsy care plans in particular, will be able to I will describe kind of strategies. Drug strategies, often your medications that that that's on the patient will respond best. If they're having a cluster seizures that could be really helpful. And then finally, don't get the other reason the seizures like you would for anyone with that. Let's see. Okay, so all the usual things do we need to treat anything specifically hypoglycemia? Alcohol withdraw. Do we need to do some other tests? Okay, fine. Okay. So we've done someone with epilepsy coming to hospital with the suspected seizure. We don't someone with epilepsy having seizures while the right hospital. Something else. I know the last one is going to be someone with epilepsy who's nearby mouth. They can't take the usual anti seizure medications. What we're going to do about that, Um so, but need to recognize it's a problem. Okay. I think we probably would agree that someone with epilepsy is just not taking the right medications for a few days. It's not going to get very well. Okay, so we have to recognize it, and then we have to do something about it. Okay? How? We're going to get the usual institution medications into them. Or if we can't, we get We need some kind of alternative. There's a temporary kind of back out while we wait. Hopefully, they're in a position to take their usual medications again. And if you know, not sure. Ask for help. So, senior on your team. Neurology for advice. Pharmacist. Pharmacist Really help from the situation. Okay. They know the different formulations of all medications that know what your hospital has. Okay, Even if some things listed that be an f is an IV formulation, it might be that it costs, you know, hundreds of thousands. Actually, hospital doesn't stock it. There's no point in the sky being that the pharmacist will be really helpful. This is a kind of take home message in this situation. Is that a recording? Only one. I think I'd expect with junior Doctors Foundation your doctors to be doing. Is this one here? I'm going to talk about the other two. Just so you're aware of the other options as well. You know, basically, the easiest thing is just to switch their normal anti seizure medication to some other kind of roots. Okay, Um, so if we can do you want to just write up IV's? And most of you said, you know, give the person and you normally take or liver trust them, give it to them IV and and it's a weekly That's the right thing to do. Never trust them is easy. All you do is do exactly the same prescription, and we want IV next to it instead of PPO. And it is exactly same two days. Easy about breaks pretty easy as well. Okay, Same dose given IV over 3/3 doses in a day, but he said, not many people on that regularly, but you can just give it IV on the coast mind. Slightly less common again. A very easy one. You just give me any of those for, you know, it's pretty straightforward. You just need to get the prescription and get the drug up and just give it to them as normal. Okay, there's other options. There's a few with aura dispersal roots seen a breakdown, development, bit of water just put in the mouth and they absorb it from in there. I mean, particularly Matra genes, for the trees are pretty good anti epileptic on Quite a lot of people are on it, but normally it doesn't have anything IV, but areas this or dispersal tablets. Okay, so that's good to be aware off to be ordered from pharmacies in a little bit of four. Planning communication. Definitely. Remember that Carbamazepine comes as a rectal suppository. So again, that could be really helpful. I'm thinking about an NGO cheap off. There's some new one mouthful surgery. You can't go and give him an NGO and feed them. But if they're know by mouth because they have stroke and swallow isn't safe, then we just, you know, probably not the best case we just need to put on ngn. I mean, if there are surgical patient in the canal years and I'm not absorbing that, that's probably not gonna work, is it? Um, but definitely an option. So in terms of the other things. If you haven't got any of these alternative that IV or a dispersal rectal roots, there's this concept of benzodiazepine bridge so you could give something like ideally around on 1 mg three times day while we're hopefully correcting whatever it is that stopping in from swallowing there usual anti seizure medications. You know it's something to just be cautious about, particularly only people who make people drowsy. Reduce this respiratory drive. And I definitely discussed that before just describing IV lorazepam regularly. Uh, sometimes what we have to do is just use one of these IV options and replace and use that in place of someone's usual anti epileptic. Okay, on, then came to just get them back into the usual ones. Could be a possible, but that would need discussion, probably with neurology. Oh, certainly with a senior on the medical team. Okay, there's your three general elections, and this is the one we need to be dressing in terms of genotoxic in terms of getting it started as quickly needs this possible, if that is an option. Okay, right. I'm just going to run through a few kind of common anti seizure medications and give my card to take home points about them. Um, there are absolutely lows. I think I picked five hits with the ones that are most likely to come across a little trust. Um, everyone's favorite also minutes checked. It's really commonly used for quite good reasons. You know, it's a pretty good anti anti convulsant. It's really easy, because the P o N I. V does exactly the same. So when people are on, well, that's what we need to do. If they can't swallow, you can use it in status. Epilepticus after your benzo does it beings, That's an option, you know, Similar to help Menotone is used. It's basically got no drug interactions, which is really nice. That's the kind of dose range they got bit on idea. I mean, in terms of side effects, long term outpatients move problems. The big one, I think if you're giving it to someone for kind of getting seizures and hospital probably drowsiness, is that one going to see the most okay, particularly puts on quite high doses of that starts that they might be sleepy because of the Levitra lasts 10, rather because of recovering from the seizures, so just bear in mind. So the valproate been around for a long time. Very good anti epileptic, used in most seizure types again, or an IV dose is thick with lint. But you should give the IV day saver eight hour day rather than 12 hours a day. Sitting just because of the It's half life again, you can use it in status. Epilepticus Uh, it's a bit more complicated than never trust on his legs, of formulations of people coming on every plane, crow and interrogate coated. They were what slightly different absorption and kind of half lives on. It's also an enzyme inhibitor, so it's got lots of interactions. You know, it's a little dirty drug in terms of interacting with other medications, so you have to check for those as we mentioned already, Mirapex m significantly reduces about trade level until always think about that. If someone's on about great and they're having the pain, it doesn't mean you can't use it if they need more opinion, which is at the end of the day a very good antibiotic, then then you know they might just need it, and we're gonna have to do something else increased evaporate or adding another anti epileptic temporarily. But just bear that in mind, okay? And there's also is high risk of congenital malformations, which I'm sure you're aware of, which is why we don't use it in women off lamotrigine. Been around a little while now, really 25 years or something again, It's pretty common is a good anti epileptic. It's generally well tolerated, you know, attended to give. It is quite a good one for our patients, but it could be a bit of a pain for inpatients when they become, um, well, so for outpatient. They didn't get very many side effects, and it's generally quite effective, but you can't give it IV. But there is a zero dispersal option. It's also somebody that has built up quite so, lease it continually take kind of 68, 10 weeks before you get to a proper treatment dose. So if someone newly has lots of seizures, were trying to get on top of quickly, it's not really that effective. It's got quite a lot of interactions as well. It's not as bad as, well, great, but it does have interactions on the camera juice exposure to the combined with Conceptive pill. So again it's one of those we just have to tap into an interaction interaction checker. If you're describing it or you're prescribing any new medications, someone who's already on it. Carbamazepine again. Quite old and two. Seizure medication Pretty good, Very good for Focalin. Set seizures can't give it IV, but there are these suppositories available's that's quite good alternative. It's got loads of interactions, so please check them. Hyponatremia pretty common can often have a mild, low sodium, just kind of normally and someone on carbamazepine. And it's got this rare side effect of a grounding. The slightest it sits on with Newly on it came out, came in. But they want cells about infection. Probably the explanation. Fine. And then, finally, I was just going to mention a bit about friend. It's ho in, basically to take home about finished. I mean, it's not loaded. Side effects is not loads of interactions. Eso It's not really used as a long term anti seizure medication anymore, although there are still a reasonable number of people who are on it 2030 years ago, just carried on because it does actually sued them quite well. Um, and it's still when we said we said use mostly in hospital for kind of status. Epilepticus just commented. You sounds often stop first line in most protocols. I think that's probably give it IV. Just be aware that there's quite a high rate of a rhythm, ears and hypertension when you're giving it IV, so the patient absolutely needs to be monitored, usually when it's been given the already way because of the mild stages. Okay, it's not quite complicated pharmacokinetics that basically means a bit like warfarin, different people, different doses to get to the same level on, Basically, you need to do trough levels. Then you take the blood. Just before that, do tater the next dose on, then interpret. That's in terms of all dream and altering and doses or checking that someone's on the right amount. When you initially started okay, so that was everything that I wanted to run through that. So let's just quickly run through the cases again, and I could tell you my thoughts on them and see if any of you changed your mind. There's never been a bit time for feedback and things at the end So this is our 64 year old man. Well controlled epilepsy on Val. Great being treated with IV matter pen in because of the exacerbation bronchitis and then house and seizures. So one of the people going to go for this time Yeah, Okay, five second move. Okay, so it's been a bit of a swinging again, a bit of a spread, I think. Hopefully got the point about meropenem reducing the concentration off study involve great. Which was kind of the point of this question, although really just a highlight that, you know, if someone normally stable epilepsy suddenly starts getting seizures is in patients. I because I haven't been taking the medications or cause we've given something that interacts. I mean, in terms of whether you should switch antibiotics, that's going to depend on the bugs they've got. There's nothing else that's it's sensitive to you kind of gonna have to carry on, and then probably we'll increase the dose of so it involves Great temporarily. Okay, fine. Second case of the ladies on liver trust, um, and is no by mouth because she's about to have her appendix taken out. So switch drive, ease which directo don't do anything or give lorazepam. Yeah, okay. Pretty much everyone going Switch to I be good. Which is which was the most popular one? Not so. That's definitely the right answer here. I don't think there's any, um, any suitable alternative for this one? Okay, last one. So, lady, with just transitions with complex epilepsy, drug resistant epilepsy, we know that cause she's on three medications, which is coming in status, and she's not responding. Teo The kind of normal hospital pro school of Barraza, Pam, and then finished again? No. Kind of. Definitely right answer here, but few things to consider. Okay. Okay. Again, A bit of a mix. Um, fine. So I think, you know, probably if you had to pick one here and actually exam situation, but we actually call it two years, and it was in the protocol is always give lorazepam. Give a second line agent like melatonin ankle I to you at the same time. Is if that's not what? What? That probably gonna need General anesthesia. I think probably probably the right answer, for example, have been call intensive care, which we did do. Um, But while they were coming and having lots of complicated discussions about whether this lady were quite severe learning difficulty, that bad epilepsy would be a candidate for long term ventilation and a seizure and things Mom would come in and was basically saying, What on earth you doing? Here's our protocol. What we do with with her. When this happens, we give a IV phenobarbital own, and it always works. Which phenobarbital is not really on very many protocols. It's very old school and politic. Agent. Uh, certainly I'm not one that I would've been reaching for without this information, but we gave it to her and she stopped seizing. So I think I put this in just a a highlight the importance of trying to get the background information in terms of someone's someone that let's see what's worked in the past talking to the family, trying to get information here. Hopefully, in this situation, someone come in with a big sheet of paper that says, This is what you do if I go into status. But if it's not any new, take up to look for it on she, um she did okay in the end. Great. Okay, so that's everything I have to say a few key points just to summarize of the end of flips is common. Really. Barry ble Some people walking around with one medication on a low dose. No seizures. Some people on five or six medications still having seizures. So it's very variable. Remember that patients and families of the experts in their own condition and expert patients, um uh, if you can't talk to them or they are able to talk to you in clinic letters and epilepsy care plans also really helpful. Ms. Medications, Most common reason procedures and some with epilepsy. So if you think they had a seizure that absolutely with the next question, I always think about drug interactions. Okay, keep giving someone new medication. Please keep an TC on medication going at all times. If you can just switch it to IV. That's easiest for everyone. But if you can't need to have to think about alternatives on, ask for some help about whether we're going to give them some benzodiazepine or different anti seizure medication. Um uh, while re address the underlying okay, great, thank you very much. That's a QR code for feedback and your certificate of attendance. And if you got any questions? I'm very happy to take them. Thanks so much again, Jacob. That's so helpful for just, uh, fortunately having done for one surgery and never managed to come across the the epileptic patient who did who was know by mouth. But that is phenomenally helpful. So I said, they can't go on the QR code. There is a link right at the top of the chapped on. Just remember you. You fill out the feedback for the QR code. That's the way you get you a certificate. So you attended this session, said please fill out. It's helpful for us and helpful for you. Uh, we're just kind of it through the chopped now. Um, getting some up would say, Can a seizure cause brain damage is the first question? Well, yes, would be the short answer. You know, ongoing ongoing seizures, candy, and and the most emergency is convulsive status epilepticus. Because that's the one that in which the neurons are firing the most and kind of using up the metabolic demands. So you kind of go, you have to get like you can get like a a knock sick brain damage like a metabolic brain damage. So that's why we need to get people. That status is quickly. It's possible there's a lot of it. Got a few more people this time is a little comments. End of filtering through, uh, say, uh, his diazepam safe is a long term seizure. Preventative. It's the max. Well, um, it's not used very commonly. I mean, some, sometimes it is necessary of be for kind of epilepsy is difficult to control with them other medications. So I guess it's an option. There's another benzodiazepine called clobazam, which is a bit newer. I think they've been around about 10 years or so. We use that a bit for people who kind of have a seizure because of something that's easily identified on reversals. It's a UTI, and they've had seizures and might give them some clubs down to say three days or something to get them over. That that trigger. But but But there are also some people who are in regular clobazam for let's see control. Yeah, that's what I was gonna say. That's the one that I keep saying hospital at the moment I was here. What? What is this? Uh huh. Uh, so I think we'll we just wait. Is anyone else got any questions? Feel free statement in the chats was wondering in terms of the of attendance, those in the UK Is there anything that should trigger so off as a sort of it, like sort of the internal medicine team thinking about, um, we'll just sort of sort of d g a. So urology abouts of referring people on for sort of consideration of, um, epilepsy surgery and sort of care is all the more tertiary center a name into this or two until collected drugs. But is there anything else that sort of do you think should spot? That's what I consider it. Well, I guess the first is is It's generally, you know, some things dying out patients with neurology. I think the guidelines, basically anyone with drug resistant epilepsy should be considered for epilepsy surgery. But I think practically if you can't talk to people who are only tried a couple of medicines well, whether they want to have kind of major neurosurgery, that most people aren't mean they quite you prefer to try some more medications. You've also then got the kind of issue about when whether someone is actually kind of technically eligible, where the epilepsy surgery can benefit them and that basically comes down to the imaging. Need to have quite quite quality imaging and see if there is actually a new area of the brain that's abnormal. And then you have to be really confident that that is where the seizures are coming from because the last thing you want to do is take a bit of someone's brain out and then you realize that the seizures are actually coming from somewhere else. Um, so you know, that kind of work up tends to be done in a tertiary center, but in terms of referring someone, you basically need to have someone who's got drug resistant epilepsy where it's kind of compromising their quality of life. And it used to be focal, onset and ideally have some kind of structure abnormality on the images that you've done. All that will probably be repeated a tertiary center and they need to be willing to engage with the process and it's quite lengthy process. I think they will get kind of psychology and neuro psychology assessments, so it's quite, you know, it's very indefinitely have to be. You have to be able to engage with that and, you know, willing to kind of go through our office or traveling involved as well, because the tertiary center might be a long way away. So you know the way up those kind of risks and benefits for an individual patient. But but but the guidelines are to consider it for anyone who's just hasn't got control after two anti convulsants, Um, just a few questions come through. Say the first thing is, do you see the use of medical marijuana in clinical practice? Um, yeah. I mean, the study lost people taking CVD oil. Never, maybe not so much epilepsy, all the conditions as well, you know, And it is licensed, isn't it, Um, for certain forms recollected, I think. I think I think hardly any prescription is actually being provided. Have a time that it has been think? Yeah, I think you know, is a which is not something I in the first year they said they had prescribed it to any about six people for the whole list of the King's college um, catchment area. So it's pretty pretty rare. From what? Why does epilepsy seem to be increasing in dementia patients. That's the next question. I don't know, but, um, I would wonder if it's just to do it kind of increasing life expectancy, increasing the rates of dementia and kind of people surviving longer with dementia would be my thoughts on that. Uh, if you got any other idea that I'll be off the top of my head, Um, yeah, that's there. There was multiple in nature neurology recently on the so topic on, let's see and so dementia in the overlap between them. But it may just be the increasing prevalence of dementia. Sounds like what you say. Um, the increased life expectancy that we're seeing. Yeah, I know I haven't read anything myself on that, Um, it's a couple more. Then we'll probably closed closed session for today on How would you approach in Albany? Patient who presents with 2 to 3 episodes of seizures now aborted. Would you should start on anti epileptic on what would be your choice, Walt strength. So I mean, that's kind of assumed that that's kind of saying that they have only had one episode cause that maybe had three seizures within 24 hours when if you had three seizures outside of 24 hours, that is a diagnosis of epilepsy, often kind of practically. You know, if someone's kind of elderly and they've got some structural brain disease such as, you know, even just small vessel disease on a scan or they had a stroke. A. We got dementia. And we often say, you know, even after a single seizure, that because there's a structural brain abnormality that they're going to be a high risk for the seizures. So you know what he would recommend anti seizure medications at that time? Um, exactly which one, you know, I mean, Levitra system gets used a lot. I think. I think, um, advantage of it in elderly patients is that is the lack of interactions because often they're on other medications as well. Um, but so that's the one probably get seen use the most that that or lamotrigine probably would be the two most common. But Valtrex used to bit as well. You know, there's no strong guidelines you've got to think about in terms of the other medications you're on, and there are other capabilities. Um, yeah, it's just two more say if you have epilepsy is a child. Is it possible that it could come back? I'm showing the questions of all. See if it's fruit now regressed. Um uh, what? So if someone's kind of being seizure free for 10 years or something and they want somebody, I mean, yes, because probably they probably they got slightly lower seizure threshold than average. And it may just be in that, you know, they've had good control and potentially some gets older. If they require, you know, other problems, then Certainly. You know, just because your epilepsy has you kind of resolved at one point, they think I don't think it will go out for the rest of your life. You know, as we know people can develop. Let's see, you've never had it before over the age of 60. So yeah, final question is, after having a stroke and then sort of only once a post stroke seizure, would you consider that person to sort of have a nap? Let's see, Diagnosis a lifetime treatment. I know this is a dissociated legal proceedings like driving limitations, etcetera. Yes, your question. Um, it depends on the timing of the seizure. Basically, there's a kind of commission for seven or 38. So basically, if you get early seizures after a stroke, that's probably just related to the acute. And so and then you might give them some Keflex to make it three months or something just to get them over that period. But certainly if someone gets seizures, you know, more than a month or so after that stroke, that very likely to have further seizures with that medication so that the key thing there is the timing with the early or late after the street. Yeah. Uh, it's actually quite personal. One third of pediatrics. Uh, so crowds say I'll just finish with this one. So is there still a correlation between February seizures and developing seizures later in life? After say, I'm no. 100% sure on on the kind of answer and date is that, um, yeah, I'm not sure. Then the father, it's lost its best in the Correlation. So yes, that there is a historical evidence that that may be a correlation somewhat there. Yeah, I don't know, actually, of stuff made, I would like to just give an answer off the cuff without being sure so sorry, All right. Thanks very much again, Jake. You Thanks very much, everyone, for coming along on that session, we were trying to make a shit. 1/4 3rd of march. Um, but no sure that we go anywhere with that at the moment. Um, the next one that we definitely your butt in is on acute stroke on the 10th of March. Say, two Thursdays. Time s. So we hope you can join us, then. Please sign up my mind. A bleak for sort of weekly Humira about the webinars. They're going on with the Ford. See you very soon.