What is the most important measure to reduce the risk of Sudden Unexpected Death in Epilepsy (SUDEP) in a patient with a history of focal to bilateral tonic-clonic seizures?

From the Guidelines

The most important measure that Lachlan can take to reduce his risk of SUDEP is to improve adherence to his current medication regimen. This is because the greatest risk factor for SUDEP is frequent seizures, especially generalized tonic-clonic seizures, as stated in the 2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death 1. By taking his prescribed medications consistently without missing doses, Lachlan can maximize seizure control, which is the best way to prevent SUDEP.

Some key points to consider in Lachlan's case include:

• The importance of medication adherence, as missed doses can lead to breakthrough seizures, which increase the risk of SUDEP
• The need for Lachlan to work closely with his neurologist to find the most effective medication regimen and ensure that he is taking his medications as prescribed
• The potential benefits of nighttime supervision, such as sharing a bedroom with someone or using a listening device, although this is not the most important measure in Lachlan's case
• The underlying mechanism of SUDEP, which likely involves postictal respiratory suppression and cardiac dysfunction following a generalized tonic-clonic seizure, highlighting the importance of reducing or eliminating these seizures through proper medication management 1.

In terms of specific actions that Lachlan can take, these include:

• Developing a plan to ensure that he takes his medications consistently, such as setting reminders or using a pill box
• Discussing his medication regimen with his neurologist to ensure that it is optimized for his specific needs
• Educating his partner about seizure first aid, although this is not the most important measure in reducing the risk of SUDEP
• Considering the use of a seizure monitoring device during sleep, although this is not the most important measure in Lachlan's case.

From the Research

Reducing the Risk of SUDEP

To reduce the risk of Sudden Unexpected Death in Epilepsy (SUDEP), several measures can be considered. The most important measure is:

• Improving adherence to the current medication regimen, as medication nonadherence is a significant risk factor for SUDEP 2, 3.

Additional Measures

Other measures that may help reduce the risk of SUDEP include:

• Avoiding sleeping alone, as having someone present during sleep can help respond to seizures 4
• Encouraging partners or caregivers to become familiar with seizure first aid, which can help respond to seizures and potentially reduce the risk of SUDEP 4
• Using a seizure monitoring device during sleep, which can help detect seizures and potentially reduce the risk of SUDEP
• Considering the addition of a second or third antiepileptic drug (AED) for patients with poorly controlled generalized tonic-clonic seizures, as polytherapy has been associated with a reduced risk of SUDEP 3

Importance of Medication Adherence

Medication adherence is a critical factor in reducing the risk of SUDEP. Studies have shown that declining adherence to antiseizure medications is associated with an increased risk of SUDEP 2. Therefore, improving adherence to the current medication regimen is essential to reduce the risk of SUDEP.