OPD Management of Epilepsy

1. Initial Assessment at OPD

• Detailed seizure history: type, frequency, duration, aura, postictal state, triggers
• Age of onset, family history of epilepsy
• Precipitating factors: sleep deprivation, alcohol, fever, stress, missed doses
• Birth history, febrile seizures, head trauma, CNS infections
• Drug history, comorbidities (psychiatric, cardiac, hepatic, renal)

• Full neurological exam
• Look for neurocutaneous markers (ash-leaf spots in tuberous sclerosis, port-wine stain in Sturge-Weber)

• EEG (interictal) - baseline and before any drug withdrawal
• MRI brain (preferred over CT; high-resolution for structural lesions)
• Serum electrolytes, glucose, CBC, LFT, RFT, thyroid function
• Drug levels (once therapy initiated)

2. Decision to Start Anti-Seizure Medication (ASM)

• Structural lesion on MRI
• Focal neurological deficit
• Significant EEG abnormality
• Strong family history
• Patient preference after counseling

3. Drug Selection - By Seizure Type

• Valproate - GABA potentiation + NMDA inhibition + sodium + T-type calcium channel inhibition; broad spectrum but teratogenic
• Carbamazepine/Oxcarbazepine - sodium channel inhibition; focal epilepsy preferred; can worsen absence/myoclonic seizures
• Lamotrigine - sodium channel inhibition; broad spectrum; risk of rash (slow titration essential)
• Levetiracetam - SV2A modulation; broad spectrum; risk of mood/behavioral disturbance
• Topiramate - multiple mechanisms; broad spectrum; cognitive impairment and weight loss common
• Ethosuximide - T-type calcium channel inhibition; absence seizures only
• Lacosamide - slow inactivation of sodium channels; focal seizures

4. General Prescribing Principles

• Start low, go slow - begin at the lower end of the dose range
• Monotherapy first - only one drug initially; switch rather than add if ineffective
• Titration - dose is increased until seizure control is achieved or side effects limit further increase
• Drug levels - useful for phenytoin (non-linear kinetics), phenobarbital, carbamazepine; less useful for levetiracetam or lamotrigine
• Polytherapy - only when two sequential monotherapies have failed; each added drug provides diminishing returns and adds adverse effects
• After failure of two appropriate ASMs at adequate doses, the epilepsy is classified as drug-resistant and referral to a comprehensive epilepsy center is indicated

5. Monitoring at Follow-Up OPD Visits

• Patient should maintain a diary recording frequency, type, duration, and any triggers

• Seizure control, adherence, adverse effects
• Mood/cognition/behavior changes
• New medications (drug interactions, especially with enzyme inducers: phenytoin, carbamazepine, phenobarbital, topiramate)

• Drug levels when adherence is in doubt or toxicity suspected
• CBC, LFT periodically (especially valproate, carbamazepine)
• Sodium levels for carbamazepine/oxcarbazepine (risk of hyponatremia)
• Bone density (long-term use of enzyme-inducing drugs)

6. AAN Quality-of-Care Standards for Epilepsy OPD (Bradley & Daroff's Neurology)

• Counseling for women of childbearing potential - at least once a year
• Referral to a comprehensive epilepsy center for patients with intractable epilepsy
• Quality-of-life assessment - at least once
• QoL outcome review - at a visit at least 4 weeks after initial assessment
• Depression and anxiety screening at every office visit (psychiatric comorbidity is very common in epilepsy)

7. Counseling and Lifestyle Advice

• Avoid unsupervised bathing/swimming
• Caution with heights, open fires, heavy machinery
• Driving restrictions (varies by country; typically 6-12 months seizure-free before permitted)
• Wear medical alert identification

• Sleep deprivation
• Alcohol (lowers seizure threshold, also interacts with ASMs)
• Missed doses
• Flashing lights (in photosensitive epilepsy)
• Excessive stress

• Avoid valproate if possible (highest teratogenicity risk - neural tube defects, fetal valproate syndrome)
• Folate supplementation (5 mg/day) before and throughout pregnancy
• Enzyme-inducing ASMs (phenytoin, carbamazepine, topiramate) reduce effectiveness of oral contraceptives - advise higher estrogen dose OCP or non-hormonal contraception
• Levetiracetam or lamotrigine are preferred in pregnancy when monotherapy is needed
• Contraception counseling at every annual visit

• Most patients can lead normal lives on adequate treatment
• Restrictions may apply to certain jobs (driving vehicles, working at heights, handling heavy machinery)

8. When to Withdraw ASM

• Obtain an EEG before withdrawal - if paroxysmal activity is present, continuing treatment is generally preferred
• Even with a normal EEG and 2 seizure-free years, relapse rate is ~33% after discontinuation, and ~40-50% at 2.5-5 years (MRC Antiepileptic Drug Withdrawal Study)
• Relapse is lower for absence and generalized-onset seizures vs. focal seizures
• Juvenile Myoclonic Epilepsy (JME) - lifelong treatment is usually required even after prolonged seizure freedom
• Patient's preference, driving concerns, and pregnancy plans all influence this decision

9. Drug-Resistant Epilepsy: OPD Approach

• Confirm the diagnosis is correct (rule out non-epileptic attacks, pseudoseizures)
• Check compliance and drug levels
• Review for an underlying structural/metabolic cause
• Refer to comprehensive epilepsy center for:
  • Video-EEG monitoring
  • Presurgical evaluation (MRI, PET, SPECT, neuropsychology)
  • Consideration of epilepsy surgery, vagal nerve stimulation, responsive neurostimulation, deep brain stimulation, ketogenic diet

10. Seizure Clusters - Rescue Therapy for Home Use

• Intranasal midazolam (FDA-approved 2019)
• Intranasal diazepam (FDA-approved 2020)
• Rectal diazepam (older option, less preferred)
• Buccal midazolam (widely used in Europe)

• Adams and Victor's Principles of Neurology, 12th Ed. - Treatment of Epilepsy chapter
• Bradley and Daroff's Neurology in Clinical Practice - Epilepsy and Quality-of-Care Standards

📋 OPD Prescription Slip

Rx

Target dose of valproate: 1000-2000 mg/day in divided doses. Titrate based on response. Max dose: 2500 mg/day.

Target dose: 1000-3000 mg/day. Fewer drug interactions; watch for mood/irritability.

Target dose: 300-400 mg/day. Monitor drug levels (therapeutic: 10-20 mcg/mL). Non-linear kinetics - small dose changes can cause toxicity.

Investigations Advised

• EEG (baseline)
• MRI Brain with contrast
• CBC, LFT, RFT, Serum electrolytes, Blood glucose
• Drug level (Valproate / Phenytoin) after 4 weeks

Instructions to Patient

1. Do not miss doses - take at the same time daily
2. Avoid alcohol completely
3. Avoid sleep deprivation and excess stress
4. Do not stop medication on your own even if seizures stop
5. Avoid driving until seizure-free for at least 6 months (follow local regulations)
6. Avoid working at heights or near open water unsupervised
7. Carry a medical ID card stating your condition and medications
8. Return immediately if: aura/warning, seizure recurrence, rash, jaundice, or behavioral change

Follow-Up

• Review at 4 weeks with EEG and drug levels
• 3-monthly follow-up thereafter if controlled
• Review for drug withdrawal consideration only after 2 seizure-free years