Managing epilepsy

Current situation

  • Epilepsy is a common, serious condition, affecting around 400,000 people in the UK.
  • There is still a lack of awareness of epilepsy. It has been estimated that 400 deaths a year are avoidable.
  • GPs play a major role in making the initial diagnosis and in long-term monitoring of epilepsy.

What is the evidence?

  • Over-diagnosis, especially in children, is still a problem. One study showed that only 10 per cent of children referred to a clinic actually had epilepsy (Arch Dis Child 2006; 91: 214-18).
  • If a patient with epilepsy starts to have more fits, it is presumed that their compliance is poor.
  • One review has shown that some patients with epilepsy show signs of tolerance to their epileptic drugs after prolonged treatment. This tolerance is reversible when the drug is stopped (Epilepsia 2006; 47: 1,253-84).
  • Data from the UK Epilepsy and Pregnancy Registry has shown that almost 96 per cent of babies born to women with epilepsy do not have a major congenital malformation (J Neurol Neurosurg Psychiatry 2006; 77: 193-8). The most effective drug should be chosen before conception and prescribed at its lowest dosage, ideally as monotherapy.
  • One study found that standard epilepsy drugs are better than newer alternatives. The authors placed valproate as the first choice in general epilepsy (Lancet 2007; 369: 1,016-26).

Implications for practice

  • NICE guidance states that all patients suspected of having seizures should be seen urgently by a specialist for diagnosis and be given individually tailored treatment.
  • Routine monitoring of anti-epileptic drug levels is not generally recommended.
  • Long-term remission occurs in more than 50 per cent of patients. So it may be possible to eventually withdraw medication.
  • The International Bureau for Epilepsy states that patients should stay on the same type of antiepilepsy drug, branded or generic, to avoid further seizures.

Guidelines

  • NICE guidelines recommend that the newer antiepileptic drugs (lamotrigine and topiramate) are used in patients who have not benefited from treatment with older antiepileptic drugs.

Dr Louise Newson is a GP in the West Midlands and author of 'Hot Topics for MRCGP and General Practitioners', PasTest 2006

Key points

  • Epilepsy management is still sub-optimal.
  • Many anti-epileptics cause unwanted side-effects.
  • Many patients may not need treatment.


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