HISTORY TO EMPHASIZE UPON
Ask for EFFECTS of the seizures :- loss of consciousness, biting of tongue, injury to self, incontinence,postictal drowsiness/ confusion.
CAUSAL history:- Drug withdrawal, Alcoholism, Diabetic on insulin/OHAs; Antiepileptic therapy,Suicidal attempts? Poisoning
Demonstration of the spell can be asked by any member who has witnessed the episode.
Look for :- Signs of meningism, Focal neurological deficits, Pregnancy, Hypertension (HT encephalopathy)
Seizures in a pregnant lady, unless otherwise proved, isecclamsia. But do consider workup formeningitis if ferbile and / or signs of meningism are present.
START ON ANTIEPILEPTIC THERAPY
POINTS TO CONSIDER :-
· Is there a need at all? (place of work, frequency of episodes)
· Choose drug based on seizure type, age, pregnancy status, DI, cost.
TAILORED ANTI-EPILEPTIC DRUGS
Assoc. condition | Drug of choice | Avoid using |
Pregnancy | Phenobarb/Carbamz | Pheny/Valp/Clonazepam |
Lactation | Valproate/(Phenyt/Carb)* | Clonaz/Lamotrigine |
SLE | Carb/Phenobarb | Phenytoin/Ethosuximide |
Liver disease | Phenobarb/Clonepam | Valp/Carbamzepine |
Renal failure | Phenytoin |
|
Obstr. Sleep Apnoea | Valproate |
|
Cranial N neuralgia | Carbamazepine |
|
Manic | Carbamz/Clonazepam |
|
Diabetic neuropathy | Carbamazepine |
|
Alcohol withdrawal | Carbamazepine | Valproate |
Porphyria | Valproate | Phenytoin/Carbmzepine Phenobarb/Primidone. |
· With caution. Avoid single dose Phenobarb- sedates infant.
· Give only one drug (except in special circumstances when control is not achieved)
Drug | Dose/divided doses | Seizure type | Steady state | Cost (100 tabs) |
>Phenytoin | 200-400mg/1/d | GTCS/PS | 5-10d | Rs.42- 93(100mg) |
$ Carbamaz | 600-1200mg/2- 3/d | GTCS/PS | 3-4d | Rs.92- 120(100mg) |
#valporic acid | 1.5-2.0g/3/d | GTCS/PS Petimal/Myoclonic S | 2-4d | Rs.200 |
~Clonazepam | 0.25- 0.5mg/kg/2/d | Petimal ? Myoclonic S |
| Rs.90 (0.5mg) |
**Phenobarb | 100-200mg/1/d | GTCS/PS | 14-21d | Rs.70 (30mg) |
*PS= Partial seizures/GTCS=Generalized tonic clonic seizures.
>Start as 100mg tid, after stabilizing, can change onto SD.
$ Start 200mg BD, increments of 200mg/d/1/week upto 800mg BD.
# Start as 600mg in divided dosage, increase at the rate of 200mg/3days till seizures controlled.
~ Start with 0.5-1.5mg/d, increase by 0.5mg/d/every 3-7 days upto a max.
** Start as a single dose at night, 60-120mg,go up by 30mg/d, 1/wk till max dose reached.
· Patient education about drug dosage, SE, and disease for compliance.
· Monitor- SE, seizure frequency, blood levels.
DRUGS THERAPEUTIC LEVEL
Phenobarb | 20-40 | ug/ml |
Carbamazepin | 5-12 | ug/ml |
Valporate | 50-100 | ug/ml |
Phenytoin | 10-20 | ug/ml |
Clonazepam | 20-80 | ug/ml |
Determine policy for termination of therapy. Seizure free 3 years at least; more chances of recurrence in those with focal seizures/ continuing EEG abnormalities/initially failed to respond totherapy. Dose reduction should be gradual over months, one drug at a time. Restart therapy if recurrence occurs with same drug and regimen. A seizure is no more difficult to control after a recurrence than before. Do not stop in a mentally retarded patient.
STATUS EPILEPTICUS
References
No references available