PEDIATRICS MCQS, TOACS, PEARLS & UPDATES FOR MRCPCH/FCPS/MCPS EXAMS: PEDIATRIC EPILEPSY: General therapeutic aspects

Saturday, April 11, 2020

PEDIATRIC EPILEPSY: General therapeutic aspects

If the diagnosis of epilepsy can be made securely on the basis of the clinical findings and further testing, an appropriate course of therapy must be decided upon. Any underlying cause of symptomatic epilepsy should be treated (causally directed treatment); moreover, the predisposition to seizures can be treated symptomatically with one or a combination of drugs (ant iepileptic drugs, AEDs). Not every epileptic seizure implies a need for treatment.

In many patients with a first seizure, it may be best to wait and see whether the event will repeat itself, as long as this presents no special danger and the parents agree. The decision whether to treat with drugs must always be taken on an individual basis, with due consideration of the patient’s personality, life situation, occupation, need to drive a car, and so forth (in older children)

The following situations are generally considered indications for treating epilepsy with drugs:

§ Two or more unprovoked epileptic seizures.

§ One or more unprovoked epileptic seizures in the setting of a known disease of the brain (epileptogenic structural lesion, encephalitis, cerebral hemorrhage, tumor, etc.).

§ Epilepsy-typical potentials on EEG.

§ Initial status epilepticus.

The general principles of the treatment of epilepsy are as follows:

§ Thorough parents education.

§ Avoidance of precipitating factors (regular sleep habits, no illicit drugs, caution with prescription drugs, and avoidance of strobe lights).

§ Treatment of the underlying disease, if any (e.g., resection of a meningioma)

§ If pharmacotherapy is indicated: choice of a suitable drug for the particular seizure type (see table).

§ Gradual increase of the dose till seizure control is achieved or intolerable side effects arise. Beware of treatment failure through under-dosing: the side effect threshold varies greatly from patient to patient and must be crossed, or nearly so, before a drug can be declared ineffective.

§ Meticulous follow-up for possible side effects, with especially close observation in the initial phase of treatment.

§ Checking for compliance, for example, with serum levels, if the drug seems to be ineffective.

§ If treatment with the first drug tried is truly ineffective despite maximal dosing and adequate compliance, switch to another drug of first choice, in gradual and overlapping fashion.

§ Combination therapy only if monotherapy fails.

§ Determination of serum levels when:

- Poor compliance is suspected.

- Toxic drug effects are suspected.

- Drug interactions are suspected, particularly those involving enzyme induction.

- An already high dose is to be raised even further.

§ Rules of thumb for the discontinuation of AEDs: the patient should be free of seizures for at least 2 years; the EEG should be free of potentials that are typical for epilepsy; traditionally, the drug is slowly tapered to o over several months (although the need for this has not been demonstrated); the patient and family must be explicitly told that seizures may recur during or after the tapering phase.

§ If a patient with focal seizures has not become seizure-free with two AEDs, the possibility of epilepsy surgery should be considered early.

§ In patients with treatment-resistant focal or generalized seizures, the seizure frequency can be reduced with vagus nerve stimulation.

Antiepileptic drugs and their indications, by type of epilepsy. The drugs are listed in alphabetic order

Choice	Focal seizures	Generalized seizures			Special epilepsy syndromes of childhood
Choice	Focal seizures with or without secondary generalization	Primary generalized tonic–clonic seizures	Absences seizures	Myoclonic seizures	West syndrome (salaam spasms)	Lennox–Gastaut syndrome (myoclonic– astatic petit mal)	Rolandic epilepsy (benign epilepsy in childhood and adolescence with central spikes on EEG)
1^st Choice	Carbamazepine Lamotrigine Levetiracetam Oxcarbazepine Topiramate Valproate	Lamotrigine Levetiracetam Topiramate Valproate	Valproate	Lamotrigine Valproate	Vigabatrin Valproate	Valproate	Carbamazepine Sultiame
2^nd Choice	Clonazepam Gabapentin Phenobarbital Phenytoin Primidone Tiagabine Vigabatrin	Phenobarbital Primidone	Clonazepam Lamotrigine Topiramate	Clonazepam	ACTH Clonazepam Levetiracetam Primidone	ACTH Carbamazepine Clobazam Felbamate Phenytoin	Valproate Phenytoin
3^rd Choice Combinations	Lamotrigine + Valproate or Lamotrigine +levetiracetam	Valproate + clonazepine or Valproate + topiramate	Valproate + ethosuximide or Lamotrigine +topiramate	Valproate + clonazepam	Lamotrigine + levetiracetam	Valproate + lamotrigine	?