epilepsy in primary care

8/6/2019 Epilepsy In Primary Care

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Epilepsy in Primary Care.

Maggie Tristram, Epilepsy Specialist

Nurse.


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Background

Epilepsy is the most common serious

neurological condition.

A GP with a list of 2000 may have 10-15

patients with active epilepsy and see 1-2 new

cases per year

Prevalence of active epilepsy is 5-10 per

1,000. 70% have potential to become seizure free.


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Scenario 1

24 year old Emily Stewart had a witnessed Tonicclonic seizure while at work in an employmentoffice. She had never had this before. The seizurewas self-limiting. She was taken to A and E while

drowsy post-ictally. She has been asked to comeand see you and told that she will need to go to theneurology clinic.

She is very shaken by what has happened andcomes to talk to you about whether she might needsome time off work. She is worried about losing her

job , but is confused about what happens next. How might you handle this? What can she expect to

happen next? What can you tell her about heremployment rights?


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First Seizures

NICE recommendation-all first seizure patients need

referral to specialist. Recommends to be seen within

2 weeks.

Dr. Yvonne Hart /Dr Jane Adcock are consultantswith specialist interest in epilepsy at the JRH.

Medical history and eye witness accounts are still the

most important components of reaching a diagnosis.

One in twenty people may have a single seizure atsome time in their life.

There is a first seizure clinic held weekly in the

neurology dept.


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Investigations

Blood tests

ECG

EEG

MRI

Important to explain that negative result

doesnt mean they dont have epilepsy.


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Treatment

Dont treat single seizures

First line treatment for partial seizures=Carbamazepine

For generalized seizures= Sodium Valproate/Lamotrigine (dependant on if woman of childbearing age).

Lots of other new treatments around, mainly

add on. SANAD Marson AG et al, Lancet 2007,369(9566):1000-15

SANAD Marson AG et al, Lancet 2007,369(9566):1016-26


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Scenario 2

Mrs Debenham comes to see you because

her 14 year old son has been diagnosed

with epilepsy. She has read about sudden

death in epilepsy and is very anxious abouthow his life is going to be restricted. What

do you advise her to tell her sons

headmaster?


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First aid


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Safety Precautions.

AVOID unguarded

heights,fires, water.

Dont have a bath when

alone in the house. Care when cooking-

microwaves are safer

Contact sports

Swimming

School trips


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Mortality

Approximately 1000 epilepsy related deaths

p.a.

Accidents and suicide

Co morbidity

Status Epilepticus

SUDEP- National Sentinel Clinical Audit

2002 (500 deaths p.a.)


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SUDEP

Sudden, unexpected, witnessed orunwitnessed, nontraumatic and nondrowningdeath in patients with epilepsy, with or without

evidence for a seizure, and excludingdocumented status epilepticus, in which post-mortem examination does not reveal atoxicologic or anatomic cause for death.

the most important risk factor is the frequencyof seizures

the more frequent the seizures, the higherthe risk.


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Information needs

Medication, possibleside effects.

Managing medicationeg concordance,

memory aids, when totake a dose if miss one.

Interactions with otherdrugs.

Free prescriptions

Driving rules

Can they drink alcohol

?strobe lights

What triggers seizures?

Monitoring seizures.

Safety precautions.

SUDEP


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Scenario 3

Emma (23) has had some episodes which werepreceded by intense deja vu feeling, and duringwhich she lost consciousness, and was a bitconfused afterwards. She has been started on

carbamazepine. She has been taking microgynonfor contraception and needs to know whether this isstill ok. What sort of epilepsy is this?

One and a half years later her symptoms remainwell-controlled she has had one fit only since

then. She and her partner want to start a family butshe has come to you for advice should shediscontinue the carbamazepine?


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Type of epilepsy

What sort of epilepsy is this?

Localisation related epilepsy i.e. seizures

arising from a localised area of the brain.

Depending on affected area symptoms may

be different but frequently stereotyped in

individual. Dj vu often associated with

temporal lobe epilepsy.


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International classification of seizures


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Contraception

Microgynon for contraception, is this still ok?

COC with enzyme inducing AEDs.

Use 50 mcg oestradiol usually a combination20+30 or 2 30s ie Microgynon30 Usually

tricycle with 4 day break.

BTB tritrate up to 100mcg oestradiol.

Norinyl 1 contains mestranol, only equivalentto 37-40 mcg of oestradiol.


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Contraception continued

No need to shorten the time between depots.

POP and implants not recommended, due to

lack of evidence.

Other methods OK.


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Emergency Contraception

With enzyme inducing AEDs.

:the dose of levonorgestrel should be

increased to a total of 3 mg (1.5 mg taken

immediately and 1.5 mg taken 12 hours later)

[unlicensed doseadvise women

accordingly]. BNF


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Pregnancy

She and her partner want to start a family?

Plan ahead! Referral to neurologist

appropriate beforehand.

Risk of baby with a malformation around

5- 6% if on one anti epileptic medication.

Sodium Valproate higher i.e. 10%.

5mg daily Folic Acid recommended for 3months before conception and 1st 3 months

of a pregnancy.


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UKpregnancy register

Carbamazepine (goody)

Sodium Valproate (baddy)

Lamotrigine (goody/baddy)

Malformation risks of anti-epileptic drugs in

pregnancy: A prospective study from the UK

Epilepsy and Pregnancy Register.

JNNP Online


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Withdrawal of medication

Should she discontinue the carbamazepine?

If seizure free for two years (all types)

withdrawal can be considered

Refer to neurologist if still want to consider

drug withdrawal. Need to discuss risk/benefit

in detail.


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Factors predictive of seizure

recurrenceAge over 16

Seizures after starting anti epileptic treatment

History of secondarily generalized tonic clonic

seizures.

History of myoclonic seizures.

EEG with spike and wave.

Short period of freedom from seizures.


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Drug withdrawal continued

If driving need to stop during withdrawal and

6 months after

Consider safety issues at work and at home.

Employers attitudes to epilepsy alsoimportant.

Do they have young children to look after on

their own?

Would be advisable to consider affect of

sleep deprivation on seizure frequency.


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Scenario 4

Geoff Peters has had epilepsy diagnosed.

He is 44 and works as a bus driver. He has

stopped driving. What can you tell him about

DVLA regulations in this situation?


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Group 2 entitlement- voc LGV/PCV

Regulations require a driver to remain

seizure-free for 10 years since the last attack

without anticonvulsant medication.

Following a solitary seizure associated witheither alcohol or substance misuse or

prescribed medication, 5 years free of further

seizures, without anticonvulsant medication is

required.


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Driving laws

Should be seizure free for one year before

reapplying for license.

Simple partial seizures are regarded as

seizures in terms of the driving laws.

If the seizures are confined to sleep, they

should establish this pattern for 3 years

before reapplying for a license.


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Scenario 5

Dilara has become unexpectedly pregnantwhile taking lamotrigine. She had a coil butunfortunately it fell out. What do you tell her

and what care is she offered in pregnancy? She has a successful pregnancy and in the

third trimester asks your advice about thebirth. She has read that people can have fitsduring delivery and she is worried about this,and she is also concerned about breastfeeding while taking medication. How mightyou advise her?


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During pregnancy

Folic acid 5mg daily

LTG levels can fall dramatically during

pregnancy (up to 50%) consider measuringlevel in early pregnancy and increasing dose

as required.

Silver Star Service

UK pregnancy register


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Seizures during labour

1%-2% increased risk of seizures during

labour

Possibly influenced by sleep deprivation and

physiological changes during labour


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Breast feeding usually OK

If LTG has been increased reduce gradually

following delivery.

Warn re sleep deprivation and caring for

small baby in context of epilepsy.


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Lamotrigine!

Has some interaction with COC.

IfBTB occurs may indicate decreased

contraceptive efficacy

Women starting COC may experience a drop

in serum levels of lamotrigine

Women stopping COC may experience an

increase in lamotrigine levels.


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Scenario 6

Peter is a 38 year old catering manager who

has been taking sodium valproate for 10

years and has been fit-free for 4 years. Prior

to this he had 2 nocturnal fits. He comes todiscuss with you whether he should stop

taking an antiepileptic drug. What are your

thoughts? What information might be

relevant?


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MRC drug withdrawal study. 1013 patients

who had been seizure free for 2 years or

more. Within 2 yrs. of withdrawal 60% seizure

free. MRC Lancet 1991; 337; 1175-1180


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Special circumstances

If the person with epilepsy decides to

withdraw medication, they should stop driving

for the period of withdrawal and for 6 months

after. If they are changing medication, caution

should also be advised.


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Question1

You are reviewing your QOF points and

have been asked to look at epilepsy. What

are the targets for epilepsy care in GP?


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Epilepsy

Indicator Points Payment Stages

Records

EPILEPSY 1. The practice can produce a register of patients

receiving drug treatment for epilepsy

2

Ongoing Management

EPILEPSY 2. The percentage of patients aged 16 and over on drugtreatment for epilepsy who have a record of seizure frequency in the

previous 15 months

4 25-90%

EPILEPSY 3. The percentage of patients aged 16 and over on drug

treatment for epilepsy who have a record of medication review in the

previous 15 months

4 25-90%

EPILEPSY 4. The percentage of patients aged 16 and over on drug

treatment for epilepsy who have been seizure free for the last 12

months recorded in the last 15 months

6 25-70%


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Take home points

How does epilepsy make you feel?

Lacking in confidence

Reluctant to go out for fear of seizures.

Leads to social isolation- depression.

Worried about safety if go out and have

seizures.

Concerned about other peoples reactions.


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Other groups

Minority black and ethnic groups

Older people

People with learning disabilities


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When to consider referral

Seizures not controlled within 2 years

Management unsuccessful with two drugs

Unacceptable side effects

Unilateral structural lesion

Psychological/ psychiatric co- morbidity

Doubt of diagnosis


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Whats being done nationally?

Practice registers

Annual review system

Practice nurse training/liaison with secondary

care.

Templates/ checklists for meeting patients

information needs and conducting reviews.


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Thank you

epilepsy in primary care

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