[Treatment of epilepsy in adults. Options and strategies]

Treatment strategies for focal epilepsy

BACKGROUND

Treatment strategies for focal epilepsy need to take account of the phase and severity of the seizure disorder, comorbidity, gender and age.

METHODS

Expert review and evaluation of major studies on the treatment of focal epilepsy.

RESULTS

Complete seizure control is most often achieved with antiepileptic drug (AED) monotherapy. In the choice of AED, possible unfavourable endocrine, cognitive or psychiatric adverse effects and their interaction with the non-seizure manifestations of focal epilepsy have to be considered. In women teratogenic risks associated with AED may be relevant. If complete seizure control cannot be achieved with the first three steps of AED treatment, epilepsy surgery becomes the most likely treatment modality to provide complete seizure control. It is proposed that AED combination treatment should be limited to two or three agents to minimize the risk of side effects, especially negative effects on cognition.

CONCLUSIONS

Recent developments in the treatment of focal epilepsy have made it easier to tailor AED therapy to patients' demographic and clinical profile.

Low risk of development of substance dependence for barbiturates and clobazam prescribed as antiepileptic drugs: results from a questionnaire study

There is no systematical research about the topic of dependence on antiepileptic drugs (AED) for patients with epilepsy, despite the fact that barbiturates and benzodiazepines comprise a potential risk of dependence. We hypothesize that there is no psychological substance dependence for patients with epilepsy, possibly because of their outcome expectations. The aim of the study was to examine these patients in terms of substance dependence. One hundred inpatients at the Lake Constance Epilepsy Center were asked about their experiences with AED in terms of dependence in a structured interview. We registered general statements about dependence of AED, markers for substance dependence, and outcome expectations. About 50% of the patients reported withdrawal symptoms and the development of tolerance, but less than 10% noticed loss of control and craving. Withdrawal symptoms and development of tolerance were significantly lower in a group of patients without barbiturates or clobazam versus patients with barbiturates or/and clobazam. There was no significant difference between these two groups in psychological criteria of dependence, that is, loss of control and craving. Outcome expectations of AED were clearly related to the efficacy against seizures, and only to a small amount to psychotropic effects. The study demonstrates that physiological variables of dependence are present more in patients with epilepsy with a permanent intake of barbiturates or clobazam, but psychological variables of dependence are rarely present in epileptic patients, with or without an intake of barbiturates and clobazam. These results confirm our hypothesis that substance dependence is not a major problem in benzodiazepines and barbiturates in patients with epilepsy. Outcome expectations seem to be related mainly to the anticonvulsant and not the psychotropic effect. This might be the reason for the absence of dependence.

[Pregnancy and epilepsy. Retrospective analysis of 118 patients]

BACKGROUND

The aim of this study was to evaluate the treatment of women with epilepsy investigated prior to or during pregnancy.

PATIENTS

One hundred eighteen women (median age 28.9 years) with idiopathic (n=43), cryptogenic (n=41), or symptomatic (n=29) epilepsy and appearing for special pregnancy planning advice at a German epileptology clinic were evaluated. All patients were investigated between 2002 and 2007.

FINDINGS

Of the study patients, 69 were seen prior to pregnancy, 41 (59.4%) were on monotherapy with antiepileptic drugs (AED), and 22 (31.9%) were already on folic acid supplementation. A change in AED medication was recommended in 50 (72.5%). Ninety-three of the patients were seen during pregnancy, most often during the first trimenon (n=44). Fifty-one (55%) were on AED monotherapy, most often with lamotrigine (n=24) or valproate (n=13). During pregnancy, seizure frequency increased in 33 women (35.5%) and decreased in 14 (15%).

CONCLUSION

Monotherapy with AED should be established if possible, and folic acid supplementation should be started prior to pregnancy.