The diagnosis and management of the epilepsies in adults and children in primary and secondary care.
The diagnosis and management of the epilepsies in adults and children in primary and secondary care.
27th October 2008
National Collaborating Centre for Primary Care - National Government Agency [Non-U.S.]
Summary,
GUIDELINE OBJECTIVE(S)
To offer evidence-based and best practice advice on the diagnosis, treatment, and management of the epilepsies in children and adults in primary and secondary care
TARGET POPULATION
Adults and children, over 28 days old, who have epilepsy and are seen in primary or secondary care settings, including pregnant women, women/girls of child-bearing age, and people with learning disabilities
Exclusions
The following populations are not included:
* Neonates (infants aged 28 days or under)
* People with febrile convulsions
INTERVENTIONS AND PRACTICES CONSIDERED
Evaluation/Diagnosis
1. Specialist assessment
2. Full clinical history with eye witness account supported by corroborative evidence
3. Physical examination (including cardiac, neurological/mental status, and development assessment)
4. Referral, when appropriate
5. Investigations, including:
* Electroencephalogram (EEG)
o Provocation techniques
* Neuroimaging (magnetic resonance imaging [MRI] and computed tomography [CT])
* Other tests
o Adults: serum prolactin, plasma electrolytes, glucose, calcium
o Children: blood and urine biochemistry
o 12 lead electrocardiogram (ECG)
* Neuropsychological assessment
6. Classification using multi-axial diagnostic scheme
Treatment/Management
Overall Approach
1. Patient/parent/family/carer education
2. Referral to specialist/support services as needed
3. Comprehensive Care Plan
Pharmacological Treatment
1. Anti-epileptic drugs (AEDs) (monotherapy/combination)
* Adults: gabapentin, lamotrigine, levetiracetam, oxcarbazepine, tiagabine, topiramate, and vigabatrin
* Children: gabapentin, lamotrigine, oxcarbazepine, tiagabine, topiramate, and vigabatrin
2. Continuation of treatment
* Blood test monitoring, as needed
3. Withdrawal of treatment
* Managed AED withdrawal
4. Referral for complex or refractory epilepsy
Psychological Treatment
1. Relaxation, cognitive behaviour therapy, biofeedback
Other Treatments
1. Ketogenic diet (Not recommended in adults; considered as adjunctive treatment in children)
2. Vagus nerve stimulation (VNS)
3. Rectal diazepam or buccal midazolam* for prolonged or rectal seizures
4. Lorazepam for sustained epilepticus
5. Refractory status epilepticus
* Adults: propofol and thiopental
* Children: midazolam or thiopental
* Individual treatment pathways
Special Populations
Women
1. Specialised patient education regarding contraception, conception, pregnancy, caring for children, breastfeeding, and menopause
2. Folic acid for women on AEDs
3. Referral to genetic counseling as appropriate
4. Vitamin K parenterally for newborns at delivery
People with Learning Disabilities
1. Full clinical history with eye witness account supported by corroborative evidence
2. Special investigations (e.g. imaging under anesthesia), as needed
3. Risk assessment
Young People with Epilepsy
1. Consulting style of medical management
2. Multidisciplinary services
3. Patient education and referral to support services
Older People with Epilepsy
1. Interventions same as for general population
People from Black and Minority Ethnic Groups
1. Additional communication and cultural information such as interpreters and translations of information about employment rights and driving
Review
1. Structured review, dependent on patient
2. Provide access to written and visual information, counseling, information about voluntary organizations, epilepsy specialist nurses, investigations, and referral, when appropriate
* Note: Buccal midazolam is currently unlicensed for the treatment of prolonged or repeated seizures.
MAJOR OUTCOMES CONSIDERED
* Recurrence of epileptic seizures
* Quality of life
* Morbidity and mortality
"
National Collaborating Centre for Primary Care - National Government Agency [Non-U.S.]
Summary,
GUIDELINE OBJECTIVE(S)To offer evidence-based and best practice advice on the diagnosis, treatment, and management of the epilepsies in children and adults in primary and secondary care
TARGET POPULATION
Adults and children, over 28 days old, who have epilepsy and are seen in primary or secondary care settings, including pregnant women, women/girls of child-bearing age, and people with learning disabilities
Exclusions
The following populations are not included:
* Neonates (infants aged 28 days or under)
* People with febrile convulsions
INTERVENTIONS AND PRACTICES CONSIDERED
Evaluation/Diagnosis
1. Specialist assessment
2. Full clinical history with eye witness account supported by corroborative evidence
3. Physical examination (including cardiac, neurological/mental status, and development assessment)
4. Referral, when appropriate
5. Investigations, including:
* Electroencephalogram (EEG)
o Provocation techniques
* Neuroimaging (magnetic resonance imaging [MRI] and computed tomography [CT])
* Other tests
o Adults: serum prolactin, plasma electrolytes, glucose, calcium
o Children: blood and urine biochemistry
o 12 lead electrocardiogram (ECG)
* Neuropsychological assessment
6. Classification using multi-axial diagnostic scheme
Treatment/Management
Overall Approach
1. Patient/parent/family/carer education
2. Referral to specialist/support services as needed
3. Comprehensive Care Plan
Pharmacological Treatment
1. Anti-epileptic drugs (AEDs) (monotherapy/combination)
* Adults: gabapentin, lamotrigine, levetiracetam, oxcarbazepine, tiagabine, topiramate, and vigabatrin
* Children: gabapentin, lamotrigine, oxcarbazepine, tiagabine, topiramate, and vigabatrin
2. Continuation of treatment
* Blood test monitoring, as needed
3. Withdrawal of treatment
* Managed AED withdrawal
4. Referral for complex or refractory epilepsy
Psychological Treatment
1. Relaxation, cognitive behaviour therapy, biofeedback
Other Treatments
1. Ketogenic diet (Not recommended in adults; considered as adjunctive treatment in children)
2. Vagus nerve stimulation (VNS)
3. Rectal diazepam or buccal midazolam* for prolonged or rectal seizures
4. Lorazepam for sustained epilepticus
5. Refractory status epilepticus
* Adults: propofol and thiopental
* Children: midazolam or thiopental
* Individual treatment pathways
Special Populations
Women
1. Specialised patient education regarding contraception, conception, pregnancy, caring for children, breastfeeding, and menopause
2. Folic acid for women on AEDs
3. Referral to genetic counseling as appropriate
4. Vitamin K parenterally for newborns at delivery
People with Learning Disabilities
1. Full clinical history with eye witness account supported by corroborative evidence
2. Special investigations (e.g. imaging under anesthesia), as needed
3. Risk assessment
Young People with Epilepsy
1. Consulting style of medical management
2. Multidisciplinary services
3. Patient education and referral to support services
Older People with Epilepsy
1. Interventions same as for general population
People from Black and Minority Ethnic Groups
1. Additional communication and cultural information such as interpreters and translations of information about employment rights and driving
Review
1. Structured review, dependent on patient
2. Provide access to written and visual information, counseling, information about voluntary organizations, epilepsy specialist nurses, investigations, and referral, when appropriate
* Note: Buccal midazolam is currently unlicensed for the treatment of prolonged or repeated seizures.
MAJOR OUTCOMES CONSIDERED
* Recurrence of epileptic seizures
* Quality of life
* Morbidity and mortality
"
