1. Pre-consultation
1. Pre-consultation
Communication issues
Epilepsy is a condition that affects the brain so is often associated with cognitive problems. This patient group needs a lot of support. The most commonly reported problems are memory issues alongside other impairments in reasoning, planning, judgement and problem-solving. Language abilities may also be affected.
Cognitive issues can affect people of all ages and may appear quite early after the diagnosis of epilepsy is made. They occur in many different seizure types, but are most frequently part of the clinical presentation in patients whose seizures originate from the temporal lobe of the brain.
Medication used to control seizures and brain surgery can also negatively affect cognition in some patients. Epilepsy is common in people with learning disability (LD), which for many people can affect communication.
Consultation tips:
- You may need to give information over a number of contacts with the patient and repeat information on subsequent contact if it has been forgotten
- Consider giving written information as back-up
- Some patients with LD may lack capacity, so you will need to discuss medication with their parent or carer if they have power of attorney
- For patients with capacity, consider asking if they would like their partner, parent, carer or friend to attend the consultation with them to help them remember and process information.
Epilepsy is usually only diagnosed once the person has had two unprovoked seizures, at which point anti-seizure medication will be started. These medicines used to be called anti-epileptic drugs (AEDs) but this term is not used widely today as the drugs do not treat the underlying epilepsy and are used to try to manage seizures. Calling them anti-seizure medicines (ASMs) is therefore considered more accurate.
Some ASMs are broad spectrum so can be used to manage focal seizures (where the abnormal electrical activity originates in a seizure focus in one part of the brain), as well as generalised seizures (where the whole brain is involved from the start and there is loss of consciousness from seizure onset). Other ASMs have a narrower spectrum of activity and may not work in certain seizure types or can actually make them worse.
When first diagnosed, the vast majority of people will be started on one of three ASMs: lamotrigine, levetiracetam or sodium valproate.
ASMs are associated with a similar range of adverse effects. Early onset side-effects include somnolence and dizziness with seizure aggravation, gastrointestinal problems and rashes also commonly featuring. Hypersensitivity reactions including Stevens Johnson syndrome, a life-threatening cutaneous reaction, is a rare but serious risk with many ASMs.
Late onset side-effects are less heterogeneous, but can include altered blood results, mood disorders and behavioural issues, suicidality and changes in weight. Patients with epilepsy will often put up with quite severe side-effects because the drug has helped with their seizure control.
The three most commonly used first-line medicines for seizures
A broad spectrum ASM with a good evidence base in both focal and generalised seizures. It requires a very slow titration. It has some interactions of note with other ASMs and other drugs, including the oestrogen component of the contraceptive pill, which can lead to lowering of lamotrigine levels. Good safety profile in pregnancy, although the oestrogen interaction means therapeutic drug monitoring throughout pregnancy is usually recommended
A broad spectrum ASM used widely in practice as it has few interactions and a relatively fast titration. Good safety profile in pregnancy, although levels can drop and monitoring is usually advised. Not currently licensed for monotherapy in generalised seizures.
Drug of choice for men and boys with generalised seizures and other forms of epilepsy. Highly teratogenic so use in women and girls of child-bearing potential is only as part of the Pregnancy Prevention Programme (PPP). Some interactions with other ASMs and other drugs. Affects vitamin D metabolism, so supplementation is recommended.
Second-line ASMs and ASM combinations
If seizure control is not achieved with one of the first-line drugs, then, depending on the seizure type and the child-bearing potential of the individual, usually another ASM mentioned above will be started. The plan is usually to titrate out the first ASM once seizure control is achieved so the patient is on monotherapy. This will hopefully help to minimise side-effects.
Often patients will have to try a number of ASMs, with many patients ultimately ending up on two or more. Finding the best combination that suits an individual can be a case of trial and error. Around 30 per cent of people with
epilepsy will have drug resistant seizures, although medication can help to reduce frequency and severity.