Epilepsy and its management (ppt)
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Epilepsy is a neurological disorder characterized by recurrent seizures that are brief changes in brain activity. The document discusses the classification, causes, symptoms, and treatment of epilepsy. It notes that epilepsy can be classified as either generalized or partial seizures depending on which area of the brain is affected. The goals of treatment are to eliminate seizures without side effects through tailored medication regimens. Left untreated, epilepsy can cause health issues, cognitive impairments, and even sudden death.
Epilepsy and its management (ppt)
- 1. Epilepsy and children By Dr.Shahnawaz M.K Dal M.B.B.S, D.P.M Consultant Neuropsychiatrist Sir Cowasjee Institute of Psychiatry Hyderabad M.K Hospital Hyderabad shahnawazbest74@gmail.com
- 2. One of the oldest known conditions Epilepsy & its management
- 3. What is epilepsy ? An epileptic seizure is a transient occurrence of signs and or symptoms due to abnormal excessive or synchronous neuronal activity in the brain. Epilepsy is a disorder of the brain characterized by an enduring predisposition to generate epileptic seizures and by the neurobiologic, cognitive, psychological, and social consequences of this condition.
- 4. Facts about epilepsy At least two animals still have epilepsy for this reason: Mexican Waltzing Mouse Papio Papio baboon
- 5. History The word ‘EPILEPSY’ derived from Greek words meaning “ To seize upon ” or “Taking held of ”. In 1870,British neurologist HUGHLINGS JACKSON defined word EPILEPSY “An excessive & disorderly discharge of cerebral nervous tissue on muscles.” This discharge may be in the form of loss of consciousness, altered psychological functions, disturbance of sensations, convulsive movements or some combination there of. So the terminology ‘CONVULSION’ is not proper as it only involves intense paroxysm of involuntary muscle contractions which is improper because this disorder may involve only alteration of the sensorium or consciousness. So the SEIZURE is the proper terminology for that.
- 6. Burden of Epilepsy Persistent stigma Cognitive problems Psychiatric disturbances Long term effects of AEDs Low quality of life Accidents Sudden death
- 7. The goals of the treatment Seizure freedom Keep the patient safe Keep the patient functional Keep the patient autonomous Seizure control and the adverse effects are pharmacodynamic measures of a drug effect on the body.
- 8. A seizure is a paroxysmal event due to excessive , hyper synchronous , abnormal discharge from the aggregate of the central nervous system. Definitions A sudden, brief disruption of the normal functioning of neurons in the brain A neurological condition causing the tendency for repeated seizures of primary cerebral origin Epilepsy is not contagious, it is not a mental illness or a cognitive disability. “Paroxysmal excessive neuronal discharge from the cortical or sub-cortical areas”
- 9. CLASSIFICATION Classification of epilepsy are based on various points…. - Idiopathic(primary) or symptomatic(secondary) - Generalized or focal - Isolated ,cyclic or repetitive GASTAUT in 1970 has refined a definition of epilepsy with the help of ILAE(international league against epilepsy) By this classification epilepsy has been broadly classified in two major groups based on EEG features & it is accepted world wide.
- 10. EPILEPSY:PREVELNCE • There are over 50 million sufferers in the world today, 85% of whom live in developing countries.1 • At least 50% of cases begin at childhood or adolescence.1 • High prevalence 3.38/1000 was found in children from Government run educational institutions.2 12/2/2015
- 11. BARRIERS TO EDUCATION • Embarrassment about having seizures in front of peers can lead to children feeling uncomfortable in the school environment. • Stigma – feelings of being different to peers – may lead to emotional problems, worry, stress and anxiety. • Bullying and reluctance to attend school as a result can lead to school refusal. • Frustration concerning the inability of school staff to understand epilepsy can impact on some young people. 12/2/2015
- 12. BARRIERS TO EDUCATION • Impact on self-esteem through negative school experiences can lead to loss of confidence and self-doubt. • Fear of seizures can impact on willingness to take part in activities. • Stressful experiences at school can trigger seizures. • Fear of Sudden Unexpected Death in Epilepsy (SUDEP) can have a negative impact 12/2/2015
- 13. Epilepsy and Related Conditions • One of the most prominent cognitive changes that occurs in people • with epilepsy is a memory problem (Zemen et al. 2012) • Epilepsy may be impacting on sleep if children are experiencing seizure activity at night and this may lead to tiredness during the day and impact on learning. • Anti-epileptic drugs (AEDs) and side effects may be impacting on learning. • Attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) will be impacting on some of the pediatric epilepsy population. • Anxiety and depression will be impacting on some of the paediatric epilepsy population. 12/2/2015
- 14. Types of Epilepsy Two major categories, namely 1.partial 2. generalised seizures. Partial seizures
- 15. Epilepsy - Pathogenesis A. Result of complex genetic mutations and environmental factors can cause • 1. Abnormal brain wiring AND/OR • 2. Chemical (neurotransmitter) imbalances AND/OR • 3. Abnormal connections made when attempting to repair an injury B. Hypersensitive neurons may exhibit a sudden or violent depolarization • 1. epileptogenic (able to cause epilepsy) • 2. Easily activated by hyperthermia, • hypoxia, hypoglycemia, hyponatremia, sensory stimulation, certain sleep phases
- 16. Clinical Manifestations Often manifests as strange sensations, emotions & behaviors (including convulsions) Many may experience the same seizure events over and over, while some have many different types of seizures that cause different symptoms each time. Patients should be evaluated thoroughly after an initial seizure (complete history) The type of seizure a person has depends on a variety of things The area of the brain affected Underlying cause of seizure • Partial or generalized •Time of day of the event •Occurred during wakefulness or sleep Known triggers • flickering light ,severe sleep deprivation
- 17. Tx Medications used to treat patients with epilepsy are called anticonvulsants. These drugs each have a different mechanism of action, but all serve to reduce the frequency of epileptic seizures. Monotherapy, treatment with a single agent, is the goal. Many seizures will stop without pharmacological intervention.
- 18. Status epilepticus & febrile convulsions. Status epilepticus is a life- threatening condition in which seizure activity is uninterrupted. Febrile convulsion is associated with temperatures101 in a child under age of 6 years .
- 20. Simple Partial Seizure Rhythmic movements - isolated twitching of arms, face, legs Sensory symptoms - tingling, weakness, sounds, smells, tastes , feeling of upset stomach, visual distortions Psychic symptoms - déjà vu, hallucinations, feelings of fear or anxiety Usually last less than one minute May precede a generalized seizure
- 21. Primary generalized (absence)seizures Secondarily generalized (spread) Partial (focal) Difference between
- 23. Complex Partial Seizure Characterized by altered awareness Confusion, inability to respond Automatic, purposeless behaviors such as picking at clothes, chewing or mumbling. Emotional outbursts May be confused with:Drunkenness or drug use Willful belligerence, aggressiveness
- 25. Myoclonus A single abrupt shock like extensor movement of a limb. Petit Mal Used to describe absence seizures as well as atypical absence. Tonic Sustained contraction of one or more muscle groups, independent of position (i.e. can be flexed, extended, or opisthotonic). Aura A generic term for a warning. A colloquial term for simplepartial seizure. Convulsion Tonic, clonic or tonic-clonic seizure Generalized Seizures INTERNATIONAL CLASSIFICATION OF EPILEPTIC SEIZURES (abridged version) Absence seizures Atypical absence Myoclonic seizures, Myoclonic jerks (simple or multiple) Clonic seizures Tonic seizures Tonic-clonic seizures Atonic seizures (astatic)
- 26. GENERALIZED TONIC- CLONIC SEIZURE
- 27. Grand mal epilepsy Petit mal epilepsy
- 28. Myoclonic seizure Atonic seizure
- 29. Status epilepticus Febrile convulsions
- 30. Between Seizures: • Normal Appearance During Seizure: • Vacant stare • Eyes roll upward • Lack of response ABSENCE SEIZURE
- 31. Includes all seizures that cannot be classified because of inadequate or incomplete data and some that defy classification in described categories. This includes some neonatal seizures, e.g., rhythmic eye movements, chewing, and swimming movements. UNCLASSIFIED EPILEPTIC SEIZURES
- 32. TREATMENT PRIORITIES No AEDs until diagnosis is confirmed If uncertainty then period of observation will clarify the epilepsy syndrome Two seizures May be started after single seizure in certain circumstances
- 33. What Is the Difference Between Epilepsy & Seizures? A seizure is a symptom of epilepsy
- 35. The Brain Is the Source of Epilepsy A seizure occurs when too many nerve cells in the brain “fire” too quickly causing an “electrical storm”
- 36. Classifying Epilepsy and Seizures Seizure types: • Partial Generalized • Simple Absence • Complex Consciousness is maintained Consciousness is lost or impaired Altered awareness Characterized by muscle contractions with or without loss of consciousness
- 37. Everything you do, you do with your brain!
- 38. Different parts have different functions, and different seizures!
- 39. Seizure Triggers Missed medication (#1 reason) Stress, anxiety Hormonal changes, Menses Dehydration Lack of sleep, extreme fatigue Photosensitivity Illicit Drug, alcohol use Certain Medications Fever in Some Children
- 40. Treatment Goals in Epilepsy Help person with epilepsy lead full and productive life Eliminate seizures without producing side effects Tailor treatment to needs of individuals/special populations : • Women, Children, Elderly, Hepatic or renal failure and other diseases
- 41. What if not treated? Seizures can be potentially life threatening with brain failure, heart and lung failure, trauma, accidents Sudden Unexpected Death in Epilepsy (SUDEP) Even subtle seizures can cause small damage in brain Long Term problems: fall in IQ, depression, suicide, Social Problems, Quality of Life
- 42. Considerations in Epilepsy Management Age and Gender Seizure Frequency Underlying Pathology Comorbidities Medication Side Effects Syndrome vs. Seizure Type
- 43. Factors That Affect the Choice of Drug Seizure type/ Epilepsy syndrome Side effects & safety Patient age Ease of Use Lifestyle Age, Sex, Childbearing potential Other medications
- 44. New AEDs offer Alternative as an add-on Alternative in case of adverse effects Less AED-AED interactions Less drug-drug interactions in specific conditions Better tolerability
- 45. Consistent use Inadequate dosage or ineffective medication Drug factors Disease Factors That Influence Response to Medication
- 46. History of Antiepileptic Drug Therapy 1857 - Bromides 1912 - Phenobarbitone 1937 - Phenytoin 1944 - Trimethadione 1954 - Primidone 1960 - Ethosuximide
- 47. History of AED therapy 1974 – Carbamazepine 1975 - Clonazepam 1978 - Valproate 1990 - Oxcarbazepine 1993 - Felbamate, Gabapentin 1995 – Lamotrigine, Levetiracetam 1997 - Topiramate, Tiagabine
- 48. Choice of AED age Life style comorbidity Adverse effects tolerability Efficacygender interactions cost
- 49. Principles of AED Selection Correct diagnosis of the type of epilepsy influences treatment, prognosis and genetic counseling. One best drug to fit the fit, fit the patient; Sequential monotherapy Use the least expensive AED (all things being equal, like efficacy). Prefer AEDs which can be taken od over bid / tid. AEDs almost never need qid dosing
- 50. Start with one AED and push the dose to clinical toxicity or seizure control. Withdraw AEDs that are not effective. Never have a patient on more than three (3) AED's. Principles of AED Selection…cont.
- 51. Principles of AED Selection… cont. Don't use combination medications (e.g., phenytoin with phenobarbital). No proof that multiple AEDs are synergistic in the treatment of epilepsy. Polypharmacy is expensive, increases side effects and increases the complexity of adjusting AEDs in the refractory patient.
- 52. Antiepileptic drug (AED) - Limitations A drug which decreases the frequency and /or severity of seizures in people with epilepsy. Treats the symptom of seizures, not the underlying epileptic condition. Improves quality of life by minimizing seizures.
- 54. Seizure Management Pharmacologic Treatment Partial seizures • Oxcarbazepine • Carbamazepine • Phenytoin • Phenobarbital • Levetiracetam • Lamotrigine • Topiramate • Lacosamide • Zonisamide Absence seizures • Ethosuaximide • Valproic acid • Lamotrigine
- 55. Seizure Management Pharmacologic Treatment Tonic-Clonic Seizures • Phenytoin • Valproic acid • Carbamazepine • Topiramate • Levetiracetam • Lamotrigine • Zonisamide Myoclonic and Atonic Seizures • Clonazepam • Lamotrigine • Levetiracetam • Infantile Spasms • ACTH • Topamax • Zonisamide • Valproic acid
- 56. Antiepileptic drugs – “newer drugs” since 1990 • Felbamate • Gabapentin • Lamotrigine • Topiramate • Vigabatrin • Oxcarbazepine • Zonisamide • Leveteracetam • Pregabalin • Rufinamide • Lacosamide
- 57. Choosing the right treatment; balancing efficacy and tolerability
- 58. New AEDs offer Alternative as an add-on Alternative in case of adverse effects Less AED-AED interactions Less drug-drug interactions in specific conditions Better tolerability
- 59. Broad Spectrum anti epileptic, used to treat refractory epilepsy Levetiracetam:
- 60. TRADITIONAL ANTI-EPILEPTIC CONCERNS • Memory impairment & Impaired attention is associated with traditional Anti-Epileptics. • Liver failure resulting in death has occurred in patients receiving Divalproex Sodium. • laboratory monitoring needed /LFTs Requires 12/2/2015
- 61. 12/2/2015 An Ideal Anti-epileptic Drug • Broad spectrum of efficacy • Goal of Epilepsy Management - Seizure freedom • Sustained efficacy • Optimal therapy with no known clinically significant drug interactions • Improved quality of life • Dosage convenience
- 62. 12/2/2015 1. Levetiracetam is a new antiepileptic drug, structurally and mechanistically dissimilar to other marketed antiepileptic drugs. 2. Levetiracetam is an anticonvulsant medication used to treat epilepsy. It is the S- enantiomer of etiracetam, structurally similar to the prototypical nootropic drug piracetam. 3. It is effective in reducing partial seizures in patients with epilepsy, both as adjunctive treatment and as monotherapy. 4. Having favorable pharmacokinetic characteristics (good bioavailability, linear pharmacokinetics, insignificant protein binding, lack of hepatic metabolism, and rapid achievement of steady-state concentrations) and a low potential for drug interaction.
- 63. 12/2/2015 MECHANISM OF ACTION • The exact mechanism by which Levetiracetam acts to treat epilepsy is unknown. However, the drug binds to a synaptic vesicle protein, , which is believed to impede nerve conduction across synapses. • appear to be important for the availability of calcium- dependent neurotransmitter vesicles ready to release their content. The lack of results in decreased action potential- dependent neurotransmission, while action potential- independent neurotransmission remains normal.
- 64. 12/2/2015
- 65. 12/2/2015 INDICATIONS • Monotherapy in the treatment of partial onset seizures with or without secondary generalization in patients from 16 years of age with newly diagnosed epilepsy. • Adjunctive therapy in the treatment of partial onset seizures with or without secondary generalization in adults and children from 4 years of age with epilepsy. • Adjunctive therapy in the treatment of myoclonic seizures in adults and adolescents from 12 years of age.
- 66. 12/2/2015 Dosage
- 67. EPICETAM-Features • Broad spectrum of potential efficacy • No hepatic induction • Well tolerated in most; good cognitive profile • Excellent safety profile • No laboratory monitoring needed
- 68. • Levetiracetam pharmacology • LEV is rapidly and almost completely absorbed after oral intake, with peak plasma concentrations approximately one hour after oral administration. Food reduces the peak plasma concentration by 20% and delays it by 1.5 hours, but does not reduce LEV bioavailability (Patsalos 2000, 2003). There is a linear relationship between LEV dose and LEV serum level over a dose range of 500–5000 mg (Radtke 2001). LEV protein binding, at less than 10%, is not clinically relevant. LEV metabolism is not dependent on the liver cytochrome P450 enzyme system. LEV is predominantly excreted unchanged through the kidneys, with only about 27% metabolized.
- 69. Mechanism of action • The exact mechanism by which levetiracetam acts to treat epilepsy is unknown. However, the drug binds to a synaptic vesicle glycoprotein, and inhibits presynaptic calcium channels reducing neurotransmitter release and acting as a neuromodulator. This is believed to impede impulse conduction across synapses
- 70. Lamotrigine Oxcarbazepine Topiramate Levetiracetam Licensed to Monotherapy ILAE Treatment Guideline (Glauser T, et al.2006 ) NICE (National Institue for Clinical Excellence 2004) guidance on newer drugs for epilepsy in adults SIGN (Scottish Intercollegiate Guideline Network, 2005) SANAD (standard and new antiepileptic drug trial (Marson et al.2007) BESET (Belgian Study on Epilepsy treatment, Legros B, et al. 2007))
- 71. SIGN(Scottish Intercollegiate Guideline Network) All AEDs are equivalent in new onset epilepsy First drugs to introduce in new onset epilepsy is standart AEDs and LTG, OXC
- 72. • Hirsutismus Alopecia • Gingiva hyperplasia Coarse face Cosmetic side effects • Hyperandrogenism Ovulatory disorders • PCOS Sperm quality, number Reproductive health • 20-30% W, 50% M; Reduced libido • Anorgasmia Sexual dysfunction Bone health • total, free thyroxine↓ Thyroid functions Peripheral neuropathies Cerebellar atrophy
- 73. CBZ VPA PB ESM PHT Somnolence * GIS * * ** Liver * Depression * * * Blood * * * * * Cognition * ** * Osteoporosis (*) (*) * * Side effects-I
- 74. Side effects-II LTG OXC TPM LEV GBP PGB Somnolence * ** * * * GIS * * ** Liver Blood Cognitive * Osteoporosis Depression Engel J, Pedley TA, Epilepsy, 2008
- 75. Idiosyncratic side effects Vigabatrin Felbamate Lamotrigine Topiramate Topiramate Oxcarbazepine Visual field defects Aplastic anemia Rash Renal stones Glaucoma Hyponatremia
- 76. Weight and AEDs Weight gain Weight loss No effect VPA GBP PGB VGB TPM ZNS FBM OXC LTG PHT LEV*
- 77. Enzyme inducers vs non-inducer AEDs Carbamazepine Phenytoin Phenobarbital Primidone Felbamate Lamotrigine Oxcarbazepine Topiramate Ethosuximide Gabapentin Levetiracetam Pregabalin Tiagabin Valproat* Vigabatrin Zonisamide Narrow- spectrum inducers Non- inducers Inducers
- 78. We love our children