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 Tonic
  clonic seizure while at work in an employment
  office. She had never had this before. The
  seizure was self-limiting. She was taken to A and
  E while drowsy post-ictally. She has been asked
  to come and see you and told that she will need
  to go to the neurology clinic.
• She is very shaken by what has happened and comes
  to talk to you about whether she might need some
  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 her
  employment 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 consultants
  with 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 at
  some 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 child
  bearing 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 about how 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 or unwitnessed,
  nontraumatic and nondrowning death in patients
  with epilepsy, with or without evidence for a
  seizure, and excluding documented status
  epilepticus, in which post-mortem examination
  does not reveal a toxicologic or anatomic cause
  for death.
• the most important risk factor is the frequency
  of seizures
• the more frequent the seizures, the higher the
  risk.

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Information needs

• Medication, possible side effects.
• Managing medication eg concordance, memory aids,
  when to take a dose if miss one.
• Interactions with other drugs.
• 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 were
  preceded by intense deja vu feeling, and during
  which she lost consciousness, and was a bit
  confused afterwards. She has been started on
  carbamazepine. She has been taking microgynon for
  contraception and needs to know whether this is
  still ok. What sort of epilepsy is this?
• One and a half years later her symptoms remain
  well-controlled she has had one fit only since
  then. She and her partner want to start a family
  but she has come to you for advice should she
  discontinue 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. Déjà 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 combination
  2030 or 2 30s ie Microgynon30 Usually tricycle
  with 4 day break.
• BTB tritrate up to 100mcg oestradiol.
• Norinyl 1 contains mestranol, only equivalent to
  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 3 months
  before conception and 1st 3 months of a
  pregnancy.

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UK pregnancy 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 recurrence

• Age 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 also important.
• 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 with
  either 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 pregnant while
  taking lamotrigine. She had a coil but
  unfortunately 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 the birth. She
  has read that people can have fits during
  delivery and she is worried about this, and she
  is also concerned about breast feeding while
  taking medication. How might you advise her?

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During pregnancy

• Folic acid 5mg daily
• LTG levels can fall dramatically during pregnancy
  (up to 50) consider measuring level 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.
• If BTB 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 to discuss 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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EpilepsyIndicator Points Payment Stages

• Records
• EPILEPSY 1. The practice can produce a register
  of patients
• receiving drug treatment for epilepsy
• 
  
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• Ongoing Management
• EPILEPSY 2. The percentage of patients aged 16
  and over on drug
• treatment 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