EpilepsyThis is an epic guideline on epilepsy from NICE, but does have some really useful stuff for us and some helpful stuff to refer to if needed. I am not summarising everything as there’s too much, but I’ve pulled out what was new to me or seemed to alter practice. I am doing a separate plog on epilepsy in women…

An excellent resource

NICE doesn’t mention it, but www.epilepsy.org.uk is excellent and has advice for every aspect of living with epilepsy that you can think of.

When a patient presents with a first epilespy fit

  • In a child, it is worth assessing their developmental status.
  • Give the patient information on how to recognise a fit, first-aid in the event of a seizure and the importance of reporting further episodes.
  • If you’re not sure if this is epilepsy, Appendix A of the guideline lists a lot of alternatives and their distinguishing features.
  • It’s not in the NICE guidelines, but patient.co.uk suggests advising patients on the driving implications, occupational implications, working with machinery and avoiding swimming or bathing unattended. This website has an excellent patient information leaflet (PIL) on first fits.
  • The patient should be seen within 2 weeks by a specialist.

Investigations for epilepsy

  • Bloods (only in an adult) – UE / bone profile / glucose.
  • ECG (in adults) – if a cardiac cause of the event is possible
  • EEG – normally done after a first seizure in adults, or a second seizure in kids. It is only done to support the diagnosis of epilepsy and to give some information on possible type. It is not used to exclude a diagnosis.
  • Imaging – MRI / CT are not routinely done, but would be requested by the specialist if necessary. It is more likely to be done in adults than in kids.

Epilepsy medication

  • Starting Medication. Mostly medication would only be started after a second fit. It may be started after a first fit under certain circumstances (eg where a second fit would be unacceptable or where an underlying condition makes another fit very likely).
  • The most commonly used medications will be sodium valproate, carbamazepine and lamotrigine. Appendix K goes into huge detail on medications, side-effects etc.
  • Status epilepticus - buccal midazolam is now the first line medication. PR diazepam would be the second line medication, but is fine to use.

Annual Reviews

Kids -  these should be done by the specialist.

Adults, cover the following topics. See the separate plog on epilepsy in women in what to cover in women:

  • Information. Ensure they have access to patient information leaflets, specialist epilepsy and voluntary organisations (e.g. “expert patients” for courses on managing chronic conditions) and specialist nurses.
  • Medication. Check for medication compliance and side-effects.
  • Cognitive problems. They may need a neuropsychological assessment if they complain of cognitive / educational or occupational functioning problems (I am not sure how we would access this though).
  • Young people - discuss choice of occupation, issues with driving and the impact that drugs, alcohol and sleep deprivation may have on their epilepsy.
  • SUDEP. Advise patients of the rare but important circumstance of Sudden Unexpected Death in Epilepsy.
  • Bloods – every 2 to 5 years in adults, assess FBC, bone profile, UE, LFT, Vit D (as medication increases risk of osteoporosis). Drug levels don’t routinely need checking, unless there are specific reasons to (eg pregnancy in some circumstances, when altering phenytoin dose, if there are drug interactions or if you suspect non-compliance or toxicity).

Stopping medication

If a patient has been seizure free for 2 years, then they may wish to consider a slow withdrawal off medication, though this will impact on their ability to drive and may cause a relapse. Withdrawal of medication should be done by a specialist.

Appendix H is very useful in these situations as it gives the chance of relapse under all sorts of circumstances

Louise Hudman

I'm a freelance GP locum in Winchester & Southampton locum chambers, and Pallant Medical Chambers Clinical Guidelines Lead Partner.

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