Seizures is periods of abnormal central neurological activity which can range from general spasticity, loss of sensations, unconsciousness to occasional absence of response. Epilepsy consists of multiple subtypes and it is important to identify them for best possible treatment options. It is advisable to seek help from neurologists early on in treatment planning.
Treatment of epilepsy in adults (stepwise treatment):
Seizures:
Step 1 – Tab. Lopez MD 2 (Lorazepam orodispersible 2 mg) – 100 mcg/kg (maximum 4 mg) if oral route possible OR inj. Lopez 2mg/ml (Lorazepam 2 mg/ml) – 100 mcg/kg (maximum 4 mg) i.v. given at a rate of 2 mg/min. Repeat the dose after 5 to 10 mins if required (maximum dose – 8 mg).
Step 2 – Inj. Fosolin (Fosphenytoin 150 mg/2ml) – 20 mg/kg i.v. at rate of 150 mg/min (maximum dose – 1000 mg).
Status epilepticus:
- Treat hypoglycaemia and electrolytes abnormality
- Inj. Optineuron (Thiamine 100 mg, Pyridoxine 100 mg) 3 ml intravenously.
- Inj. Lopez followed by inj. Fosolin as above.
- If there is no improvement – inj. Thiopental along with ICU input.
Prevention of epilepsy in adults (stepwise treatments):
Newly diagnosed focal seizures
Step 1 – Tab. Levepsy 500 (Levetiracetam 500 mg) – one tablet twice a day. Increase dose by 500 mg twice a day every 2 weeks till maximum dose of 3 gm per day.
Step 2 – Tab. Topaz 25 (Topiramate 25 mg) – one tablet once a day. Increase dose by 25 mg every week till maximum dose of 200 mg twice a day.
Step 3 – Cap. Neugaba 75 (Pregabalin 75 mg) – one capsule twice a day. Increase dose by 75 mg every week till maximum dose of 300 mg twice a day.
Newly diagnosed GTC (generalised tonic clonic) seizures
Step 1 – Tab. Lovax 300 (Oxcarbazepine 300 mg) – one tablet twice a day. Increase dose by 300 mg/day every 3 days till maximum dose of 1200 mg twice a day.
Step 2 – Tab. Levepsy 500 (Levetiracetam 500 mg) – one tablet twice a day. Increase dose by 500 mg twice a day every 2 weeks till maximum dose of 3 gm per day.
Absence seizures
Step 1 – Syrup Absenz 250mg/5ml (Ethosuximide 250mg/5ml) – 10 ml once a day. Increase dose by 250 mg every week till maximum dose of 1500 mg per day.
Step 2 – Tab. Lamepil 25 (Lamotrigine 25 mg) – one tablet once a day. Increase dose by 25 mg every two weeks till maximum dose of 200 mg twice a day.
Step 3 – Tab. Topaz 25 (Topiramate 25 mg) – one tablet once a day. Increase dose by 25 mg every week till maximum dose of 200 mg twice a day.
Myoclonic seizures or juvenile myoclonic epilepsy
Step 1 – Tab. Levepsy 500 (Levetiracetam 500 mg) – one tablet twice a day. Gradually increase dose by 500 mg twice a day every 2 weeks till maximum dose of 3 gm per day.
Step 2 – Tab. Topaz 25 (Topiramate 25 mg) – one tablet once a day. Increase dose by 25 mg every week till maximum dose of 200 mg twice a day.
Step 3 – Tab. Zapiz 0.25 (Clonazepam 0.25 mg) – one tablet thrice a day. Increase dose by 0.5 mg every 3 days till maximum dose of 20 mg per day.
Tonic, atonic seizures or Lennox–Gastaut syndrome
Step 1 – Tab. Lamepil 25 (Lamotrigine 25 mg) – one tablet once a day. Increase dose by 25 mg every two weeks till maximum dose of 200 mg twice a day.
Step 2 – Tab. Topaz 25 (Topiramate 25 mg) – one tablet once a day. Increase dose by 25 mg every week till maximum dose of 200 mg twice a day.
Dravet syndrome
Step 1 – Tab. Topaz 25 (Topiramate 25 mg) – one tablet once a day. Increase dose by 25 mg every week till maximum dose of 200 mg twice a day.
Step 2 – Tab. Zapiz 0.25 (Clonazepam 0.25 mg) – one tablet thrice a day. Increase dose by 0.5 mg every 3 days till maximum dose of 20 mg per day.
Benign epilepsy with centrotemporal spikes, Panayiotopoulos syndrome or late-onset childhood occipital epilepsy (Gastaut type)
Step 1 – Tab. Lamepil 25 (Lamotrigine 25 mg) – one tablet once a day. Increase dose by 25 mg every two weeks till maximum dose of 200 mg twice a day.
Step 2 – Tab. Levepsy 500 (Levetiracetam 500 mg) – one tablet twice a day. Gradually increase dose by 500 mg twice a day every 2 weeks till maximum dose of 3 gm per day.
Step 3 – Cap. Neugaba 75 (Pregabalin 75 mg) – one capsule twice a day. Increase dose by 75 mg every week till maximum dose of 300 mg twice a day.
Adults with childhood absence epilepsy, juvenile absence epilepsy or other absence epilepsy syndromes
Step 1 – Syrup Absenz 250mg/5ml (Ethosuximide 250mg/5ml) – 10 ml once a day. Increase dose by 250 mg every week till maximum dose of 1500 mg per day.
Step 2 – Tab. Lamepil 25 (Lamotrigine 25 mg) – one tablet once a day. Increase dose by 25 mg every two weeks till maximum dose of 200 mg twice a day.
Step 3 – Tab. Zapiz 0.25 (Clonazepam 0.25 mg) – one tablet thrice a day. Increase dose by 0.5 mg every 3 days till maximum dose of 20 mg per day.
Withdrawal of pharmacological treatment:
- Consider reducing anti-epileptic drugs if patient is seizure-free for at least 2 yrs.
- Reduce anti-epileptic drugs very slowly and only one drug should be withdrawn at a time.
- Care should be taken when withdrawing benzodiazepines and barbiturates (may take up to 6 months or longer) because of the possibility of drug-related withdrawal symptoms and/or seizure recurrence.
General advice:
- Advice ketogenic diet
- Provide safety alerts to patients to ensure prompt treatment in case of epileptic fits.
Investigations:
- MRI epilepsy protocol – to identify structural pathology
- Random blood sugar – to rule out hypo or hyperglycaemia
- Renal function tests – to modify dosage as per renal functions
- Complete blood count – to identify agranulocytosis as a side-effect from anti-epileptics
- Urine pregnancy test – most anti-epileptics have teratogenic effects
- Liver function test – to modify dosage as per hepatic functions
- Serum ammonia levels – to monitor hepato-toxicity as a side-effect from anti-epileptics
- Toxicology screening – to rule out differential causes of epilepsy
- Serum Prolactin – to rule out carcinoma
- Electro-encephalogram – to identify type of epilepsy
- Lumbar puncture – to identify evidence of bleed or infection
- Chest x ray, Blood culture – to rule out infective causes of seizures
- ECG, Echocardiogram, Carotid doppler and Holter monitoring – to rule out cardiac causes of seizures
- Urine routine and culture – to rule out UTI which can cause altered sensorium
Referral:
All cases should be referred to neurologists for initial management or for patients with complications.