Diskusi

Pakar

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 Kejang/bangkitan
Apakah selalu epilepsi?

Tentukan, apakah benar itu kejang/bangkitan (epileptic

seizure)?
Tentukan etiologi kejang? VITAMINDO
SEMENTED
STOP KEJANG SEGERA!!

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Patophysiology

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 Patophysiology

Kejang disebabkan karena ada ketidakseimbangan

antara pengaruh inhibisi dan eksitatori pada otak
terjadi karena :
• Kurangnya transmisi inhibitori
– Contoh: setelah pemberian antagonis GABA,
atau selama penghentian pemberian agonis
GABA (alkohol, benzodiazepin)
• Meningkatnya aksi eksitatori  meningkatnya aksi
glutamat atau aspartat

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 Definition of Seizure and Epilepsy (1)
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.

The definition of epilepsy requires the occurrence of at least one epileptic seizure

Fisher RS et al., Epilepsia. 2005; 46(4):470-472

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 Definition of Epilepsy and Seizure (2)
Epilepsy is a disease of the brain defined by any of the following conditions:
 At least two unprovoked (or reflex) seizures occurring > 24 h apart
 One unprovoked (or reflex) seizure and a probability of further seizures similar to the
general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the
next 10 years
 Diagnosis of an epilepsy syndrome

Epilepsy is considered to be resolved for individual who had an age-dependent epilepsy

syndrome but are now past the applicable age or those who have remained seizure-free for the
last 10 years, with no seizure medicine for the last 5 years

Fisher RS et al., Epilepsia. 2014; 55(4):475-482

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Classification of Epilepsy and Seizure
Multilevel:
 Seizure type
 Epilepsy type
 Epilepsy syndrome
 Etiology
 Comorbidity

New terminology:
 Developmental and epileptic encephalopathy
 Self-limited and pharmacoresponsive

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 Goal of Management
 Freedom from seizures and adverse events

 Avoid drug interactions

 Adherence to therapy

 Minimal interference with daily life meet

Challenge to the health care provider is to these

goals with monotherapy

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 Principles Management of Epilepsy

o Physicians should adopt a consulting style that enables patient and their family
to participate as partners in all decisions about their healthcare, and take fully
into account their race, culture and any specific needs.
o Epilepsy’s patients should have a comprehensive care plan that is agreed
between the person, their family and/or careers as appropriate, and primary
and secondary care providers.
o The AED (anti-epileptic drug) treatment strategy should be individualized

NICE clinical guideline 137, January 2012

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Approach of Management

 Medication is mainstay  Pharmacotherapy

 Ketogenic diet

 Vagal nerve stimulation

 Surgery

By Paula Peterson, APRN, FNC, PNP, LPN2007, November/December 2007 14

Mechanism of action

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Medication
 Starting treatment
 Choice of AED
 Initiating treatment
 Maintenance therapy
 Stopping treatment

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Starting treatment
There is still controversy related with “when treatment should be initiated:
 After first seizure if the diagnosis of epilepsy has been established
 Focal seizures without to bilateral seizures : more than two seizures
 First generalized tonic–clonic seizure: immadiately

Diagnosis of epilepsy is essential

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Choice of AED
Individualized

Glauser T et al. Epilepsia. 2006; 47(7): 1094-1120

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 AED for Seizure types & Epilepsy
(adopted from ILAE 2013)

Seizure Type or epilepsy syndrome Class 1 Class II Class III Level of efficacy &Effectiveness evidence
studies studies studies
Adult with partial onset seizures 4 1 34 Level A: CBZ, LEV, PHT, ZNS
Level B : VPA
Level C: GBP, LTG, OXC, PB, TPM, VGB
Level D: CZP, PRM

Children with partial-onset seizures 1 0 19 Level A: OXC

Level B: None
Level C: CBZ, PB, PHT, TPM, VPA, VGB
Level D: CLB, CZP, LTG, ZNS

Elderly adult with partial onset seizures 1 1 3 Level A: GBP, LTG

Level B : None
Level C: CBZ
Level D: TPM, VPA

Adult with generalize onset tonic-clonic 0 0 27 Level A: None

seizures Level B: None
Level C: CBZ, LTG, OXC, PB, PHT, TPM, VPA
Level D: GBP, LEV, VGB

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 AED for Seizure types & Epilepsy
(adopted from ILAE 2013)

Seizure Type or epilepsy Class 1 Class II Class III Level of efficacy &Effectiveness evidence
syndrome study study study
Children with generalize- 0 0 14 Level A: None
onset tonic clonic seizures Level B: None
Level C: CBZ, PB, PHT, TPM, VPA
Level D: OXC

Children with absence 1 0 7 Level A: ESM, VPA

seizures Level B: None
Level C: LTG
Level D: None

Benign Epilepsy with 0 0 3 Level A: None

centrotemporal spikes Level B: None
(BECTS) Level C: CBZ, VPA
Level D: GBP, LEV, OXC, STM

Juvenile myoclonic Level A: None

epilepsy (JME) Level B: None
Level C: None
Level D: TPM, VPA

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ILAE 2013 Recommendations:

 Based on available efficacy and effectiveness evidence alone, for adults with newly diagnosed
or untreated partial-onset seizures, CBZ (level A), PHT (level A), and VPA (level B) should be
considered as candidates for initial monotherapy.
 Based on available efficacy and effectiveness evidence alone, for children with newly
diagnosed or untreated partial onset seizures, OXC (level A) should be considered a
candidate for initial monotherapy.

Epilepsia, 47(7):1094–1120, 2006, Blackwell Publishing, Inc.C: 2006 International League Against Epilepsy 22
Initiating treatment

 Monotherapy first
 Low dose, gradually increase until effective dose or side effect
occurred
 If the initial treatment is unsuccessful, then monotherapy
using another drugs
 The combination therapy should be considered when
attempts at monotherapy have not resulted in seizure
freedom

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Maintenance of treatment

 Detection of non-adherence to the prescribed medication

 Suspected toxicity
 Adjusment of phenytoin dose
 Management of pharmacokinetic interactions
 Specific clinical condition i.e status epilepticus, organ failure,
certain situation in pregnancy

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Stopping of treatment

 Seizure free for 2-5 years (PERDOSSI 3 years) and has normal EEG
 Approved by patient and family
 Gradually, 25% from last dosage every month within 3-6 months
 If combined, start with 1 additional AED

Depends on:
 The seizure syndrome
 Long term prognosis

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Ketogenic Diet

 Rigid food plan

 High fat, essential proteins, low carbohydrates
 Requires high level of family commitment
 Mixed results of decrease in seizures with medication
 Small number of children seizure-free

By Paula Peterson, APRN, FNC, PNP, LPN2007, November/December 2007

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Vagal Nerve Stimulation
 Surgical implantation (usually in patient’s neck) of a device delivering electrical
stimulation to the vagal nerve
 Adjunctive therapy in reducing the frequency of seizures
 Indicated if refractory to AED but who are not suitable for resective surgery
 Decrease in seizures reported with quicker recovery, not seizure-free

By Paula Peterson, APRN, FNC, PNP, LPN2007, November/December 2007

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Caring for Your Patient
o Education of family and/or support system is key
o Education about what to do during seizure
o Education about medications and treatments
o Referrals for family support

By Paula Peterson, APRN, FNC, PNP, LPN2007, November/December 2007

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Thank You

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