TREATMENTS FOR SEIZURE DISORDERS

     Last week’s column was devoted to a description of “grand mal seizures”.  A very concerned grandfather had asked about the nature of grand mal seizures and what could be done to treat them.

     The first point to make was that not all grand mal seizures need to be treated.  Young children who have very high fevers may have a seizure once or twice with the fever and then never again.  Obviously these do not need to be treated. There is however, a condition called “epilepsy”.  By this is meant a person who has repeated seizures without an obvious inciting event. The seizures seem to come on randomly and repeatedly.  As mentioned last week if the seizure were to occur when a person is in a precarious situation significant harm can occur.  The grandfather had asked what treatments were available to prevent his grandson from having further seizures and how long the grandson would have to take medication.

     To answer the second question first, epilepsy requires life long medication.  Even with life long medication, there are often breakthroughs in which the person may have an occasional seizure in spite of treatment.  In studies done to see if it is possible to stop medications for individuals with epilepsy, 30-40% of individuals will have recurrent seizures within a year of medication being stopped.  Thus, the recommendation is for the individual to be on lifelong medication.

     From historical standpoint, the very first treatment for seizures was described in 1837 with a chemical called bromide.  For 70 years, this was the only medication available to stop grand mal seizures although it is rarely ever used now.  It had a substantial toxicity and controlling the right level was very difficult.

     In 1908, phenobarbital was found to be effective in preventing seizures in grand mal epilepsy.  The side effects from this medication include significant drowsiness.  It is also a tricky medication to use because it changes the metabolism of several other important medications.  Phenobarbital can accelerate the elimination of some medications rendering them ineffective or can slow excretion of other medications making them toxic.  In spite of this, phenobarbital is still frequently used to treat epilepsy at this time.

     In 1938, research scientists discovered a medication that looked very much like phenobarbital but did not cause the drowsiness as does phenobarbital.  This product was called diphenylhydantoin (Dilantin).  Now 65 years later, this medication is still a mainstay and very effective treatment for multiple forms of epilepsy.  The dose can often be taken all at one time at bedtime making it very convenient.  The side effect profile is remarkably benign.  Perhaps the most important side effect is Dilantin’s interference with Vitamin D.  Vitamin D stimulates bone growth and without it elderly individuals tend to become osteoporotic and break their bones.  Thus individuals who use Dilantin need to take at least 800 units a day of Vitamin D in order to protect their bones.  Blood tests are available to monitor the drug level of Dilantin making control of the medication relatively simple.

     In 1965, the family of drugs called benzodiazepines (Valium, Librium, Xanax, Klonopin) became available.  These medications had dramatically few side effects and were a significant benefit in decreasing the incidence of seizures in people with epilepsy.  While the addictive potential of these medications remains a problem, they are otherwise remarkably safe.

     In 1974 another mainstay medication called carbamazepine (Tegretol) was introduced to the United States market.  There are some individuals who are intolerant to Dilantin or not controlled by Dilantin and Tegretol can be used in its place.  Tegretol can cause the person’s white cell production to be stopped in rare individuals but other than this, the side effect profile is remarkably safe.

     In the mid 1990’s a medication called lamotrigine (Lamictal) became available.  This medication is probably more effective than Dilantin or Tegretol but in today’s world is used primarily as an add-on to those medications for individuals not controlled.  Lamictal is also a remarkably safe drug but substantially more expensive.

     In 1978, a medication called Valproic acid (Depakote) was introduced on the market.  This medication is used primarily to treat something called “absence seizures”.  Absence  seizures occur primarily in children and seem to have an hereditary basis.  Children with an absence seizure problem will be talking and carrying on normal activity then suddenly stop what they are doing and simply not respond to what is going on around them for 10-15 seconds.  Their consciousness then returns as though nothing has happened.  I know that most parents think all their children have something like this.  Fortunately, the true syndrome of absence seizures (old name petit mal epilepsy) is relatively rare.  The problem of absence seizures can be effectively treated with valproic acid.

     The specialty doctors who care for individuals with epilepsy are called neurologists.  There are relatively few of them available.  Referral to a neurologist for help in diagnosing individuals with epilepsy or in treating them may sometimes be necessary.  For the most part epilepsy and seizure disorders are cared for by the healthcare providers at your local clinics.  Drug levels can be monitored there, side effects monitored, and effectiveness of the program maintained.  Occasionally, an adjustment of medications is necessary but this also can be done through your local clinics and primary care providers.

     I reassured my grandfather patient that his grandson would be able to lead a relatively normal life with the exception of having to take a medication each day.  The onus of this seems relatively small considering the alternative of having the recurrent seizures.