What are the guidelines for managing epilepsy?

Guidelines for Epilepsy Management

Epilepsy management should follow a structured approach with monotherapy using standard antiepileptic drugs (carbamazepine, phenobarbital, phenytoin, or valproic acid) as first-line treatment, with drug selection based on seizure type and patient characteristics. 1

Diagnosis and Initial Assessment

• Non-specialist healthcare providers can be trained to recognize and diagnose convulsive epilepsy 1
• EEG and neuroimaging should not be used routinely for diagnosis in non-specialized settings but reserved for specialized facilities when needed for etiological diagnosis 1
• Antiepileptic drugs should not be routinely prescribed after a first unprovoked seizure 1

First-Line Treatment Selection

For Focal (Partial) Seizures:

• Carbamazepine is preferred for children and adults with partial onset seizures 1
• Initial dosing for adults and children over 12 years: 200 mg twice daily, increasing weekly by up to 200 mg/day to optimal response 2
• Initial dosing for children 6-12 years: 100 mg twice daily, increasing weekly by up to 100 mg/day 2
• Initial dosing for children under 6 years: 10-20 mg/kg/day divided twice or three times daily 2

For Generalized Seizures:

• Valproic acid is the treatment of choice 3
• Valproic acid should be avoided in women of childbearing potential if possible 1

Treatment Approach

1. Start with monotherapy:

   • Select drug based on seizure type, patient age, and comorbidities
   • Titrate to the minimum effective dose
   • Target maintenance doses: 800-1200 mg/day for carbamazepine in adults 2

2. If first drug fails due to adverse effects:

   • Substitute with another appropriate first-line agent 4

3. If first drug fails due to lack of efficacy:

   • Consider either substitution or add-on therapy (both approaches show similar efficacy) 4
   • When using combination therapy, combining drugs with different mechanisms of action may be more effective 4

4. For drug-resistant epilepsy (failure of two appropriate antiepileptic drugs):

   • Consider referral for surgical evaluation 5
   • Vagal nerve stimulation (VNS) may be considered, with approximately 51% of patients experiencing ≥50% reduction in seizure frequency 5

Special Populations

Women with Epilepsy:

• Use monotherapy at minimum effective dose 1
• Avoid valproic acid if possible 1
• Avoid polytherapy 1
• Prescribe folic acid supplementation 1
• Standard breastfeeding recommendations apply for common antiepileptic drugs 1

People with Intellectual Disability:

• Should have access to the same investigations and treatments as the general population 1
• Consider valproic acid or carbamazepine instead of phenytoin or phenobarbital due to lower risk of behavioral adverse effects 1

Duration of Treatment

• Consider discontinuation of antiepileptic drugs after 2 seizure-free years 1
• Decision to withdraw should consider clinical, social, and personal factors with involvement of patient and family 1

Adjunctive Management

• Provide information and advice on avoiding high-risk activities 1
• First aid education should be routinely given to patients and family members 1
• Consider psychological treatments as adjunctive therapy:
  • Relaxation therapy
  • Cognitive behavioral therapy
  • Psychoeducational programs
  • Family counseling 1

Management of Status Epilepticus

Without IV Access:

• Administer rectal diazepam 1
• IM phenobarbital may be considered when rectal diazepam is not possible 1

With IV Access:

• Administer IV benzodiazepine (lorazepam preferred over diazepam) 1
• For sustained control or continuing seizures, administer IV phenobarbital or phenytoin 1

Common Pitfalls to Avoid

• Using EEG or neuroimaging routinely in non-specialized settings 1
• Starting antiepileptic drugs after a single unprovoked seizure 1
• Using polytherapy as initial treatment 1
• Continuing ineffective medication without considering alternatives 4
• Failing to consider surgical options for drug-resistant epilepsy 5
• Not providing adequate patient education about safety and first aid 1

By following these guidelines, clinicians can optimize seizure control, minimize adverse effects, and improve quality of life for patients with epilepsy.