Epilepsy in adults.
Epilepsy in adults.
27 October 2008
Singapore Ministry of Health - National Government Agency [Non-U.S.]
Summary,
GUIDELINE OBJECTIVE(S)
To help general practitioners address frequently encountered and important issues on epilepsy in adults on the topics of diagnosis, treatment and other aspects of management
TARGET POPULATION
Adults in Singapore with epilepsy
INTERVENTIONS AND PRACTICES CONSIDERED
Diagnosis
1. Distinguishing provoked versus unprovoked seizures
2. Electroencephalography (EEG) with photic stimulation and hyperventilation
3. Long-term video or ambulatory EEG
4. Electrocardiogram
5. Blood testing for metabolic abnormalities
6. Lumbar puncture
7. Magnetic resonance imaging (MRI)
8. Computed tomography when urgent assessment is needed or MRI is contraindicated
9. Referral to a specialist following first seizure
Initial Treatment
1. Antiepileptic monotherapy (first line therapy) with carbamazepine, phenytoin, or sodium valproate
2. Antiepileptic monotherapy with other agents (lamotrigine, phenobarbitone, clonazepam, clobazam, topiramate)
3. Add-on medications for suboptimal response to first line therapy (gabapentin, lamotrigine, topiramate, levetiracetam, tiagabine, zonisamide, oxcarbazepine)
4. Therapy for women of childbearing age or who are pregnant (antiepileptic monotherapy, folate supplementation)
5. Seizure precautions
6. Seizure first-aid
7. Home and workplace safety
8. Breastfeeding and antiepileptic therapy
Immediate Management of Seizure
1. Physical protection
2. Establishment of airway, breathing, and circulation
3. Record keeping
4. Dextrose (if hypoglycaemic)
5. Thiamine (if malnourished or with suspected ethanol abuse)
6. Intravenous diazepam or lorazepam for prolonged seizures
7. Notification of emergency medical services, if indicated
Follow-on Treatment and Management
1. Assessment of drug compliance
2. Assessment of drug toxicity
3. Titration of phenytoin dose
4. Metabolic and liver function blood tests
5. Second-choice monotherapy with phenytoin, carbamazepine, or sodium valproate
6. Adjunctive antiepileptic therapy (vigabatrin, lamotrigine, gabapentin, topiramate, tiagabine, oxcarbazepine, levetiracetam)
7. Changing formulations or brands of drugs (not recommended)
8. Withdrawal of pharmacotherapy
9. Vagus nerve stimulation
10. Complementary treatment (acupuncture, chiropractic, herbal medicine, homeopathy, osteopathy, yoga, some aroma therapy) (not recommended)
11. Ketogenic diet (not recommended)
12. Control of precipitating factors
MAJOR OUTCOMES CONSIDERED
* Number of seizures
* Frequency of seizures
* Duration of seizures
* Treatment adherence
* Incidence of pharmacotherapy side effects
Singapore Ministry of Health - National Government Agency [Non-U.S.]
Summary,
GUIDELINE OBJECTIVE(S)To help general practitioners address frequently encountered and important issues on epilepsy in adults on the topics of diagnosis, treatment and other aspects of management
TARGET POPULATION
Adults in Singapore with epilepsy
INTERVENTIONS AND PRACTICES CONSIDERED
Diagnosis
1. Distinguishing provoked versus unprovoked seizures
2. Electroencephalography (EEG) with photic stimulation and hyperventilation
3. Long-term video or ambulatory EEG
4. Electrocardiogram
5. Blood testing for metabolic abnormalities
6. Lumbar puncture
7. Magnetic resonance imaging (MRI)
8. Computed tomography when urgent assessment is needed or MRI is contraindicated
9. Referral to a specialist following first seizure
Initial Treatment
1. Antiepileptic monotherapy (first line therapy) with carbamazepine, phenytoin, or sodium valproate
2. Antiepileptic monotherapy with other agents (lamotrigine, phenobarbitone, clonazepam, clobazam, topiramate)
3. Add-on medications for suboptimal response to first line therapy (gabapentin, lamotrigine, topiramate, levetiracetam, tiagabine, zonisamide, oxcarbazepine)
4. Therapy for women of childbearing age or who are pregnant (antiepileptic monotherapy, folate supplementation)
5. Seizure precautions
6. Seizure first-aid
7. Home and workplace safety
8. Breastfeeding and antiepileptic therapy
Immediate Management of Seizure
1. Physical protection
2. Establishment of airway, breathing, and circulation
3. Record keeping
4. Dextrose (if hypoglycaemic)
5. Thiamine (if malnourished or with suspected ethanol abuse)
6. Intravenous diazepam or lorazepam for prolonged seizures
7. Notification of emergency medical services, if indicated
Follow-on Treatment and Management
1. Assessment of drug compliance
2. Assessment of drug toxicity
3. Titration of phenytoin dose
4. Metabolic and liver function blood tests
5. Second-choice monotherapy with phenytoin, carbamazepine, or sodium valproate
6. Adjunctive antiepileptic therapy (vigabatrin, lamotrigine, gabapentin, topiramate, tiagabine, oxcarbazepine, levetiracetam)
7. Changing formulations or brands of drugs (not recommended)
8. Withdrawal of pharmacotherapy
9. Vagus nerve stimulation
10. Complementary treatment (acupuncture, chiropractic, herbal medicine, homeopathy, osteopathy, yoga, some aroma therapy) (not recommended)
11. Ketogenic diet (not recommended)
12. Control of precipitating factors
MAJOR OUTCOMES CONSIDERED
* Number of seizures
* Frequency of seizures
* Duration of seizures
* Treatment adherence
* Incidence of pharmacotherapy side effects
