Dr. Elinor Ben Menachem MD, PhD,
Professor at the Sahlgrenska academy at the university of Gothenburg, Sweden. Elected to the Board of Directors of the American Epilepsy Society(2019-2021), Author of over 100 original articles & over 30 review articles and book chapters.
A neurological disorder that affects 65 million people around the world, epilepsy is characterized by unprovoked, recurrent seizures. Although it is more common among young children and older adults, it occurs more in the male population rather than female. Treatment options for epilepsy may vary based on the severity of symptoms and patient’s response, and include implants (vagus nerve stimulator) that prevent seizures, dietary changes (ketogenic diets), antiepileptic drugs, and epileptic surgery that involves removal of the brain area that causes seizure activity.
Only 10 percent of those with epilepsy can undergo epileptic surgery. It is important for doctors to tailor treatment based on patient needs and take into account comorbidities (one or more disorders that occurs with the primary disorder). Many comorbid conditions are associated with epilepsy and they must be limited, prevented or reversed during treatment. When treating patients with new antiepileptic drugs (like Brivaracetam, Lacosamide, Rufinamide which is in a ballon) doctors must start with low doses and slowly increase dosage after carefully noting patient responses. When using new drugs, treatment must be tailored based on efficacy and possible side effects exhibited by the patients. Factors that influence treatment include age (children, adults and elderly), hormonal effects in women, psychiatric comorbidities (like psychiatric behavioral disorders, depression, anxiety, psychosis, attention deficit disorder, autism), drug-drug reactions where the patient is being treated with multiple antiepileptic drugs and for other conditions, fertility issues, chronic side-effects, weight gain, etc. Epilepsy can also result in unfavorable social situations like dropping out of school/university, unemployment, substance abuse, suicide, difficulties in child-bearing and even unexpected death (SUDEP).
Treatment with Anti-epileptic Drugs and Side Effects
The side-effects in patients must be carefully observed even after the drug has been successfully tested in clinical trials. This is because patient responses may vary, and treatment must be altered accordingly. While prescribing drugs, doctors must be mindful of the patient’s seizure type and syndrome, age, gender, co-medication, individual lifestyle, and ensure their adherence to anti-epileptic drugs. It is also important to keep in mind drugs that can’t be prescribed in certain cases, for instance a drug like valproate cannot be prescribed to women of childbearing age unless it is the last option. Doctors must also learn when to prescribe a broad-spectrum or narrow-spectrum drug, understand the long term effects, and the mechanisms of action, and look for indications as to how good they are for monotherapy in new onset epilepsy for adults or children and if there are neuropsychological implications, and whether dosage must be stopped or reduced based on these reactions. One of the issues that doctors deal with is ensuring that the drugs prescribed are in regular supply from pharmacies. If newer drugs are involved, whether the patient can afford them becomes an issue and cheaper drugs may be prescribed. Doctors must understand that chronic side-effects of some older (and less expensive) drugs can lower the quality of life for patients like weight gain or pain in shoulder/hands,and polyneuropathy. Physicians must try to avoid prescribing valproate or at least lower its dosage for child-bearing women as it increases the risk of teratogenic major malformations. Women may also face issues with menstruation and develop polycystic ovaries, so precautions must be taken while prescribing drugs. Side-effects like hostility, depression, irritability, insomnia and aggression may occur in case of some anti-epileptic drugs and dosage must be lowered to avoid these effects. Monitoring side-effects is essential while tailoring treatment for an epilepsy patient.