CCE: Seizure Disorders Management Strategies

"If you don't have a good handle on epilepsy, it can be frightening. It still startles me when I see a seizure," says David M. Treiman, MD, director of the Epilepsy Center at Barrow Neurological Institute in Phoenix, Arizona.

"Epilepsy is barely taught in medical schools," he says. Furthermore, there is still a stigma attached to the disorder. Although there has been much improvement during the past two decades in terms of educating neurologists and primary care physicians in the use of antiseizure medications and as to when a referral to a neurosurgeon is warranted, primary care physicians should not hesitate to call an epileptologist for advice. "A few simple questions answered in a couple of minutes would greatly enhance the care for a patient," says Treiman. "It doesn't require the PCP to become an expert."

The goal of seizure disorder management is to render the patient seizure-free without side effects. This usually requires referral to specialists but all the experts at our Clinical Centers of Excellence agree that there are many things primary care physicians can keep in mind when seeing patients who are struggling to reach a seizure-free state.

Uncontrolled seizures

The first thing to consider when medication is not controlling seizures in a recently diagnosed patient is a misdiagnosis. "Many patients with epilepsy are misdiagnosed," says Orrin Devinsky, MD, director of the New York University Comprehensive Epilepsy Center. "Some do not have epilepsy. Others have a different epilepsy syndrome than the one diagnosed, which has important therapeutic implications."

When the diagnosis is accurate and the medication has previously worked, breakthrough seizures can occur. According to Devinsky the most common reasons for breakthrough seizures are missed medication, sleep deprivation, excessive alcohol consumption, and illness.

In general, if seizures are chronically uncontrolled or if medication side effects are persistent, patients should be referred to a specialty center for evaluation or in some cases, reevaluation. Tim Powell, MD, an epileptologist at Rockwood Clinic, Spokane, Washington, agrees. He recommends referral after the failure of a second antiseizure drug so that a correct diagnosis and more aggressive therapy options or surgery can be considered.

Medication Management

Overall, primary care physicians should keep in mind that the older medications, such as phenytoin, phenobarbital, and carbamazepine are associated with significant drug-drug interactions and cause more chronic side effects, including bone loss. Devinsky says that newer antiepileptic agents should be considered whenever possible.

"Primary care physicians should never discontinue an epileptic patient's medication without working with a neurologist no matter how long it has been since the patient had a seizure," advises Judd Jensen, MD, a neurologist who refers patients to the Massachusetts General Hospital Epilepsy Service. He says it happens frequently.

Powell offers the following medication management tips.

• Pay attention to dosing and medication details pertaining to different patient populations including children, adolescents, women, and the elderly.
• Female patients may continue taking antiepileptic medications during pregnancy and may also breastfeed while taking these drugs with some caveats. New guidelines developed by the American Academy of Neurology and American Epilepsy Society recommend women with epilepsy avoid taking valproate during pregnancy as evidence shows that valproate is linked to increased risk for fetal malformations and decreased cognitive skills in children. The guidelines also recommend that women with epilepsy avoid taking more than one epileptic drug at a time during pregnancy since taking more than one antiseizure drug has also been found to increase birth defects compared to taking just one drug. The guidelines further state that pregnant women with epilepsy avoid taking phenytoin or phenobarbital to reduce the possibility of decreased cognitive skills in their children.
• Drug interactions are particularly common among elderly patients

Lifestyle management

Seizures are disabling and may prevent patients and their families from engaging in normal activities. It is particularly important to watch for red flags indicating depression or increased risk of suicide in these patients, Powell says.

He also advises primary care physicians to inquire about and become aware of any specific unmet needs or issues families or caregivers may have because often, these will affect their ability to adequately care for patients with seizures.

Finally, it is important to involve patients in the decision-making process when developing a therapeutic plan. "Otherwise, they will not follow your recommendations," Powell says.