EPILEPSY

1. A background to epilepsy:

a) How is a diagnosis of epilepsy made? Outline the tests a neurologist may request to aid in
making a diagnosis.
EEG  electroencephalogram is most common, electrodes record electrical activity of your
brain. Also, neuroimaging, neurological examination.

b) Outline the most common types of seizures and describe what the patient experiences for
each type.
- Absence seizures – brief twitches affect specific parts of the body or only eyelids.
- Myoclonic seizures – sporadic (isolated) jerking movements.
- Tonic-clonic seizures (generalized) – jerking movements, muscles becoming weak or limp,
muscle twitching, convulsion, unconsciousness.

c) Outline the factors that increase the likelihood of a seizure occurring.

Differs from person to person but commonly are tiredness and lack of sleep, stress, alcohol and
not taking medication.

d) Sodium valproate and carbamazepine are both first line drugs for tonic-clonic seizures.
When is one prescribed over the other?
Non-compliance is a common reason; when patients are unable to tolerate.

e) List the factors prescribers should consider in choosing an appropriate drug for patients with
epilepsy. Why are these factors important?
Diagnosis of seizure type, and if possible, epilepsy syndrome are the most important factors for
drug selection.

f) If seizures are not controlled by the first antiepileptic drug, what is the protocol for drug
therapy moving forward?
Before changing the drug treatment, check compliance with the prescribed regimen, plasma
concentration monitoring, ensure dose of 1 st line of drug is maximal with minimal side effects,
reevaluate, confirm the diagnosis, if still ineffective add on alternative 1 st line or 2nd line drug,
when optimal dosage of the 2nd drug is achieved, gradually reduce dosage of the 1 st drug.

g) Withdrawing an antiepileptic drug is a process that is complex and requires intense

monitoring. What are some situations you can think of that would require
withdrawing/ceasing antiepileptic drug therapy? Does withdrawing an antiepileptic drug
impact on a patient’s ability to drive a car? If so, what impact does it have?
This can be attempted after 2-3 years without seizure, presence of absence seizures only,
younger age when seizure control is achieved, normal EEG, normal neurological examine and
absence of brain lesions. If stopped abruptly increased seizure and status epilepticus may occur.
When withdrawing reduce dosage of anti-epileptic drug over several weeks/months, 6 months
longer for barbiturates or Benzodiazepines, withdraw one drug at a time.
2. A 26 year old female present you with the following prescription. She has just been diagnosed
with epilepsy and has not used these medications before.

Rx: Epilim 100mg (1 bd)

Epilim EC 200mg (1 bd)

a) Provide your thoughts on the starting dose of Epilim for this patient.
Avoid in women of child-bearing potential due to teratogenic risk. If no other alternative, use the
lowest does possible and ensure adequate contraception.

b) Provide full counselling to this patient, including side effects.

With food to reduce stomach upset, swallow whole, don’t crush or chew, may cause drowsiness,
if affected, don’t drive/operate machinery, it increases effects of alcohol so pay attention to a
healthy diet to avoid weight gain, inform doctor if fever, rash, abdominal pain, vomiting,
jaundice, bruising/bleeding develops, don’t stop taking this medication suddenly unless told by
doctor.
c) List the monitoring points for sodium valproate when used as an antiepileptic.
Check complete blood count including platelets before starting treatment, routine monitoring of
liver aminotransferase concentration, it reduces BMD and increases fracture risk, conside BMD
monitoring during long-term and ensure vitamin D and Ca intake are adequate. Measure plasma
concentration for toxicity and compliance.

d) List the other indications for sodium valproate.

Neuropathic pain, migraine, birth defects, bipolar disorder.

e) How would you modify your counselling if you were counselling sodium valproate for the
indications listed in part (d)?
Same counselling as (b).

f) Discuss the importance of contraception for women taking Epilim

Avoid if possible as it increases risk of neural tube defects, spina bifida and other cardiac,
urogenital and limb defect, minimize risk by using lowest dose: <1000mg/daily.

g) What needs to be considered before starting contraception prior to taking other

antiepileptic drugs?
If planning, consider and discuss the possibility of selecting a specific antiepileptic drug. Risks of
unplanned, treatment withdrawal need to be discussed, as it can cause spina bifida neural birth
defects if withdrawn, can give 5mg folic acid 1 month before and 3 months after contraception
in these women, if necessary, although evidence is limited.

Fast forward three years. The patient seeks your advice because she is trying to fall pregnant
and wants to know whether it will be safe for her to continue to take Epilim.

h) How do you respond? What are the recommendations for a pregnant woman with epilepsy?
The incidence of congenital malformation in infants  mothers treated with antiepileptic is 2-3
 times higher than general people. Increased risk if increased dose.

3. A 32-year-old male presents you with a prescription for Tegretol 100mg (1 bd).

a) Provide your thoughts on the starting dose of Tegretol for this patient. Would you expect
the dose to change in the coming weeks/months? If so, what dose would you expect to see?
Initially 100mg oral bd, increase daily dose gradually by 100-200mg every 2-4 weeks according
to response. Usual range 400-1200mg daily in 2 or more doses, up to 2g daily.

b) Is therapeutic drug monitoring (TDM) necessary for patients taking carbamazepine? What
benefits may a prescriber get from monitoring concentration levels of antiepileptic drugs?
Regular plasma concentration monitoring may not be usually useful, but it is used to assess
compliance for some days or renal failure. It is useful to monitor plasma concentration after a
seizure if dose is dependent. Doctors, some patients may become seizure free/experience dose
dependent adv effects at subsequent therapeutic concentration while others can tolerate
concentration beyond therapeutic range.

c) Provide full counselling to this patient, including side effects.

With food to prevent stomach upset swallow whole, don’t crush/ chew, drowsiness dizziness,
blurred vision (start of tx) or when dose is increased, increases effect of alcohol, avoid grapefruit
juice, tell doctor before starting to take new medications (herbal/OTC drugs). Tell doctor
immediately if rash, sore throat, fever, mouth ulcers, bruising/bleeding occurs, don’t stop
medication unless doctor advise, BMD monitoring during long term tx, ensure vit D and Ca intake
are adequate.

d) List the monitoring points for carbamazepine.

Routine plasma concentration monitoring e.g. just after a seizure if dose dependent adverse
effects occur, after a change in dosage, or if interacting drugs are started/stopped.

e) List the other indications for carbamazepine.

Trigeminal neuralgia, acute manic and mixed in bipolar I disorder (when other medications don’t
work), nerve pain by diabetes.

4. A patient presents you with a script for Lamictal 25mg (1 d for 2 weeks, then increase every 2
weeks as directed by your doctor). Upon questioning you discover the patient is currently
taking Epilim.

a) Provide your thoughts on the starting dose of Lamictal for this patient. If it is inappropriate,
provide an appropriate starting dose. Justify the dose you believe to be appropriate.
Can be used as monotherapy in partial/generalized seizures, adjunct to treatment. Use is limited
because of severe rxs as Steven Johnsons Syndrome and tonic epidermal neurolysis. It doesn’t
auto-induce its metabolism and has less interaction potential, alternative to pts who can’t
tolerate CMZ.
 b) Lamotrigine can cause severe skin reactions. What are these skin reactions called? How do
they physically present and in what situation(s) are they more likely to occur?
Steven Johnsons Syndrome. Tonic epidermal necrolysis, diplopia, blurred vision, dizziness,
headache, somnolence, hyperkinesis, nausea, maculopapular rash.

c) Provide full counselling to this patient, including side effects.

Swallow whole, can cause drowsiness, increases effects of alcohol, tell immediately if rash, fever,
or swollen glands, don’t stop taking medication unless advised by doctor.

5. A patient presents you with a prescription for Topamax 25mg (1 nocte). The patient is
currently taking Lamictal. The doctor has prescribed Topamax as adjunct therapy.

a) What are your thoughts on the co-prescribing of topiramate and lamotrigine? In your
answer, consider what each drug could potentially be used for.
Can be used as adjunct therapy for bipolar and focal seizures, generalized as it affects
lamotrigine metabolism.

b) Provide full counselling to the patient, including side effects.

Tablets may be swallowed whole, chewed, or dispersed in a small amount of water. Can cause
drowsiness, dizziness, or blurred vision, if affected, don’t drive, or operate machinery. It increases
the effects of alcohol, tell the doctor immediately if you develop a rash, fever, or swollen glands,
don’t stop taking this medicine suddenly unless advised by your doctor.

c) List the monitoring points for patients taking topiramate.

Stop treatment as quickly as possible if acute onset or decreased visual ocular pain occur.
Monitor for decreased sweating and hyperthermia; especially in hot weather, risk is increased if
combined with other drugs e.g. anticholinergics. Measure serum bicarbonate concentration
during treatment, if metabolic acidosis develops and persists, reduce dose, or stop topiramate.

d) List the other indications for topiramate. Have you seen any prescriptions recently for
topiramate being used off label? If so, discuss what you have seen in the pharmacy.
Partial seizures with or without secondary generalization, prevention of migraine (adjunct
generalized tonic-clonic seizures.

6. A mother presents you with a prescription for Keppra Liquid 100mg/mL (give 3mL bd) for her
8-year-old son. The child has just been diagnosed with epilepsy.

a) The child’s mother has heard “bad things” regarding Keppra and is hesitant about giving it to
her son. Her main concern is the behavioral issues it can cause. Provide full counselling to
the mother, including side effects, and address her concerns.
Can cause drowsiness. Increase alcohol effects, can be diluted in glass of water, don’t stop taking
unless advised by doctor. Used for myoclonic seizures in juvenile myoclonic epilepsy >12 years.
Behavioral effects include depression, emotional liability, hostility, aggression, agitation, anxiety
and nervousness.