Management of epilepsy

What is the situation?

  • Epilepsy is a common, serious condition, affecting around 400,000 people in the UK.
  • It is estimated that 400 deaths a year due to epilepsy  are avoidable. 
  • GPs play a big 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: 214–8).
  • A change in the type of anti-epileptic medication can lead to breakthrough seizures in 1–2 per cent of patients because of tiny differences in the components of the products (BMJ 2005; 331: 720).

The International Bureau for Epilepsy states that doctors should ensure that patients stay on the same type of anti-epilepsy drug to avoid further seizures. 

  • When a patient with epilepsy starts to have more fits, it is usually presumed that their compliance is poor. But 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).
  • The most effective drug should be chosen before conception and prescribed at its lowest dose, ideally as monotherapy. 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).

Implications for practice

  • NICE guidance states that all patients suspected of having seizures should be seen urgently by a specialist for diagnosis.
  • The manufacturers of Depo-Provera and the FFPRHC state that enzyme inducers do not appear to reduce the efficacy of injectables, and the interval length should remain at 12 weeks. NICE recommends a 10-week interval. 
  • Routine monitoring of anti-epileptic drug levels is not generally recommended.
  • Long-term remission occurs in more than 50 per cent of patients.

Further reading

  • NICE recommends that lamotrigine and topiramate are used for the management of epilepsy in patients who have not benefited from treatment with older antiepileptic drugs.

Useful websites — NICE — Joint Epilepsy Council

Department of health — the Long-term Conditions National Service Framework — Epilepsy Action (British Epilepsy Association) — International Bureau for Epilepsy — FFPRHC (Faculty of Family Planning and Reproductive Health Care)

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

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