To what extent can drug treatment help in patients with epilepsy

A: There has been a significant improvement in the drug treatment of epilepsy in the last few decades. The world wide experience is that complete control of seizures can be expected with appropriate drugs in almost 75% of newly diagnosed, previously untreated patients of epilepsy. The choice of drugs mainly depends on the type of seizures in a given patient. Drug treatment should only be started when the diagnosis of epilepsy has been established beyond doubt. To begin with it is always better to start with a single most appropriate drug (monotherapy). It is not recommended that patients should be started with two or more anti-epileptic drugs (polytherapy). The drug chosen is usually introduced gradually, in small doses because most drugs have some side effects if these are introduced rapidly. The final maintenance dose is usually built up over a period of a few weeks.

Q: How long the treatment should be continued?

A: The duration of treatment is dependent upon many factors like the type of epilepsy, age of the patient, control of seizures etc. In most cases, however, the treatment is continued for a period of 3 years after achieving complete seizure control. The treatment should never be stopped suddenly and the decision to stop treatment must be taken by the doctor in-charge of the patient.

Q: What are the main principles of drug treatment for epilepsy?

A: The principles of drug treatment in epilepsy are:

• The seizures can be completely controlled in almost 60-70% of newly diagnosed untreated cases of epilepsy.
• Most patients can be treated with one or a maximum of two anti-epileptic drugs.
• The choice of drug is made on the basis of seizure type and the previous response to the treatment, if any.
• The dose of drugs is maintained so that it produces the maximum control of seizures without any toxicity or side effects.
• The importance of regular treatment and its objectives must be understood by the patient and family members. Anti-epileptic treatment will not be successful without the co-operation and proper understanding of the patients.
• The reduction of dosage or withdrawal of anti-epileptic drug should always be performed slowly and in consultation with the doctor incharge of the patient.

Q: Why is it important to take anti-epileptic drugs regularly?

A: The aim of taking anti-epileptic drugs is to obtain adequate control of fits. It is very important to maintain a constant level of the drugs in the brain to control seizures. In order to achieve that, a constant level of the drug in the blood is required. It is therefore, very important to take medicines regularly.

Q: What is the effect of anti-epileptic drugs on behaviour?

A: Most anti-epileptic drugs do not have any effect on the behaviour. Phenobarbitone (Gardenal or Luminal) and its related drug called Primidone (Mysoline) are known to cause over activity in about one third of the children who are treated with these drugs.

Q: Can epilepsy be cured?

A: Epilepsy can not be cured in the real sense of the term. Epilepsy is a disease like hypertension, asthma and diabetes mellitus. Seizures can be totally controlled in almost 75% cases with epilepsy. In some people, especially children the seizures never recur after stopping their anti-epileptic treatment. These people can be considered to be cured of their epilepsy. In addition, very few people can be cured of their fits by surgical means.

Q: What is the risk of seizure recurrence after stopping anti-epileptic treatment?

A: A number of factors are known to influence the risk of relapse of seizure after withdrawal of medications in patients who have been seizure free for 2-3 years while on treatment. In no individual case can the safety of anti-epileptic withdrawal be absolutely guaranteed. Usually, almost half the cases whose treatment is stopped go into complete remission. If a patient has epilepsy secondary to brain damage or partial seizures, the risk of seizure recurrence is much higher and in most such cases, the treatment should be continued for many more years even if the seizures are controlled. It is a common experience that among patients being considered for withdrawal of anti-epileptic drugs, recurrence of seizures is most common while the drugs are being withdrawn or soon after the withdrawal is completed. In our experience the maximum risk of seizures recurrence is within three months of the drug withdrawal. If a patient has no fits for 4 to 5 years after the drug withdrawal, then his/her chance of having recurrence of seizure is extremely small.

Q: Should the anti-epileptic drug be discontinued during any other intercurrent illness?

A: It is very common mistake to stop the anti-epileptic drug when the patient has fever or nay other intercurrent illness. The anti-epileptic drugs should never be stopped in such circumstances. If the patient vomits within an hour or so of taking the drugs, an extra dose can be given after some time. It must always be remembered that the medicines used in the treatment of the intercurrent illness can have some pharmacological interactions with the anti-epileptic drugs. It is always better to inform the treating physician about the patient’s dosage schedule of the anti-epileptic drugs so that necessary precautions can be taken.

Q: What should be done if the patient forgets to take a dose of anti-epileptic drugs?

A: It is not uncommon for many patients to forget to take a dose of their anti-epileptic medication once in a while. Very often the patient may not even remember if a dose was taken or not. In such a situation it is better to take an extra tablet within the same 24 hours period rather than risking the occurrence of seizure due to low levels of the drugs in patient’s blood.

Q: Can a person with epilepsy and on treatment with anti-epileptic drugs take alcoholic drinks?

A: An occasional drink or a glass of beer is unlikely to have any bad effect o a person who is on treatment with anti-epileptic drugs. However, it must be remembered that:

• After a couple of drinks, it is very easy to forget taking the anti-epileptic drugs. This can result in seizures getting precipitated.
• Alcohol affects the brain and slows one down. Some of the anti-epileptic drug especially phenobarbitone has the same affect and it is best to avoid such combinations.
• Heavy drinking can provoke seizures especially during the morning after an alcoholic binge.
• Prolonged alcohol intake can damage the liver. As with most other drugs, anti-epileptic medications are also broken down in the body by the liver. Abnormal liver function as a result of alcoholic damage can change the effectiveness of anti-epileptic drugs.

Q: What should be done if some one gets an epileptic fit on the road side or any where else?

A: It is important to know what should NOT be done if some one is having a fit.

• DO NOT attempt to force anything between the teeth, as a spoon or wooden piece can break the teeth while a cloth can cause choking. Even if the tongue gets bitten, it usually heals in the next few days.
• DO NOT attempt to stop the convulsive movements as it may result in injury to the person.
• DO NOT allow people to crowd around the convulsing person.
• DO NOT put a shoe, onion or any other thing in front of the patient’s nose.

On the other hand, DO THE FOLLOWING:

• Allow the seizure to be completed. Turn the patient on to one side and ensure that he/she can breathe freely.
• Shift the patient away from any dangerous place/object and loosen all the tight clothing.
• The patient may be confused after the fit, and may need to the reassured with sympathy but without fuss.
• Help the patient so that he/she can continue his/her activity. Transfer the patient to a doctor/hospital if the patient gets recurrent fits, has injury or does not become conscious.

Q: How frequently should a person with epilepsy visit the treating doctor?

A: This is mostly an individual decision but if the epilepsy is well controlled, a check-up once in 3-4 months is enough. Persons who have poorly controlled seizures or are on multiple drugs may need to visit the doctor more frequently. In certain situations like epilepsy and pregnancy, epilepsy in the elderly and recurrent febrile convulsions more frequent visits may be required.

Q: What is the effect of fits on the memory?

A: A single or occasional fit usually does not have any effect on the memory. However, very frequent seizure, fits of long duration and certain type of fits (temporal lobe seizures) can have effects on the memory. In addition, therapy with multiple anti-epileptic drugs or even a single drug in heavy dosage can also contribute to the memory loss complained by persons with poorly controlled epilepsy. In such patients nothing much can be done about the memory problems and the best thing is to try and achieve optimal seizure control with minimum drugs.

Q: Can seizures cause brain damage?

A: A single brief seizure probably causes no permanent damage to the brain. Prolonged grand-mal seizures or even febrile convulsions can definitely damage the brain. In addition, seizures occurring one after the other without the patient becoming conscious in between two seizures, can also damage the brain. It is an accepted fact that any seizure lasting for 20 to 30 minutes can results in brain damage which is not secondary to the fit itself but results from the lack of oxygen supply to the brain during the prolonged fit.