What are the guidelines for treating epilepsy?

Guidelines for Epilepsy Management

The first-line treatment for epilepsy is antiepileptic drug (AED) monotherapy, with drug selection based on seizure type, epilepsy syndrome, and patient characteristics, aiming for complete seizure freedom while minimizing adverse effects. 1

Diagnosis and Classification

• Classify seizures and epilepsy syndrome through:

  • Detailed seizure description
  • EEG findings
  • MRI of brain (standard for structural causes)
  • Consider MR spectroscopy and PET for additional diagnostic information 2, 1

• Epilepsy types:

  • Focal epilepsy (most common)
  • Generalized epilepsy
  • Combined focal and generalized
  • Unknown 2

Treatment Algorithm

Initial Treatment Approach

1. Start with monotherapy at lowest effective dose 1

   • Up to 70% of patients achieve seizure freedom with optimum AED therapy 3
   • 47% of patients achieve seizure freedom with first AED trial 2
   • Additional 14% achieve seizure freedom after second or third AED 2

2. Drug selection based on seizure type:

   • Focal epilepsy:

     • First-line: Oxcarbazepine, lamotrigine
     • Alternative: Levetiracetam (avoid if psychiatric history) 1, 4
     • Carbamazepine: Initial dose 200mg twice daily for adults, 100mg twice daily for children 6-12 years 5

   • Generalized epilepsy:

     • First-line: Valproate (avoid in women of childbearing potential)
     • Alternatives: Lamotrigine, levetiracetam 1, 4

   • Juvenile myoclonic epilepsy:

     • Levetiracetam shown to reduce myoclonic seizure days by 60.4% vs 23.7% with placebo 6

3. Titration and dosing:

   • Carbamazepine: Increase at weekly intervals by adding up to 200mg/day using three or four times daily regimen 5
   • Maintenance dose usually 800-1200mg daily for adults 5
   • For children under 6 years: 10-20mg/kg/day divided twice or three times daily 5

Management of Refractory Epilepsy

1. If first drug fails due to inefficacy:

   • Switch to alternative monotherapy from different drug class 1

2. For patients failing two AEDs (refractory epilepsy):

   • Consider add-on therapy rather than substitution 3
   • Referral to epilepsy center for surgical evaluation 7
   • Epilepsy surgery renders 60-70% of temporal lobe epilepsy patients seizure-free 7

3. Status epilepticus management:

   • First-line: Benzodiazepines 2, 1
   • For refractory status epilepticus (failed benzodiazepines):
     • Administer IV phenytoin, fosphenytoin, or valproate 2, 1
     • Valproate shown to be as effective as phenytoin with potentially fewer adverse effects 2
     • Alternative options: IV levetiracetam, propofol, or barbiturates 2, 1

Special Considerations

Women of Childbearing Potential

• Avoid valproic acid due to teratogenic risk 1
• Consider lamotrigine or levetiracetam as alternatives

Patients with Comorbidities

• 25-50% of epilepsy patients have neurologic, psychiatric, cognitive, or medical disorders 4
• Avoid enzyme-inducing AEDs (carbamazepine, phenytoin) in patients with cardiovascular disease due to risk of hyperlipidemia 4
• Consider levetiracetam in patients without psychiatric history 1, 4

Seizure Prophylaxis

• Prophylactic antiseizure drugs have not been demonstrated to be beneficial after intracerebral hemorrhage 1
• Only treat clinical seizures or electrographic seizures in patients with altered mental status 1

Treatment Discontinuation

• Consider discontinuation after 2 seizure-free years 1
• 60% of treated patients remain in remission off AEDs 8
• Avoid abrupt discontinuation which can precipitate withdrawal seizures 1

Patient Safety and Education

• Provide comprehensive education on:

  • Seizure management techniques
  • Medication adherence importance
  • Safety precautions for daily activities
  • Avoiding high-risk activities 1

• Emergency services should be called for:

  • Seizures lasting >5 minutes
  • Multiple seizures without return to baseline
  • Breathing difficulties after seizure
  • Injury during seizure
  • First-time seizure
  • Seizure occurring in water 1

Monitoring and Follow-up

• Regular follow-up to assess:
  • Seizure frequency and characteristics
  • Medication efficacy and side effects
  • Quality of life impact
  • Need for medication adjustments 1
• Consider therapeutic drug monitoring for optimizing dosage 1, 3