Management
First choice treatment for epilepsy is anti-seizure medication. These are preventive drugs: they do not treat a seizure once it has started. The Epilepsy Society estimates that seizures could be prevented in up to 70% of people with epilepsy with optimal treatment.1
Factors to consider when choosing a drug include: seizure type; age; sex; risks and benefits; drug interactions; comorbidities; patient preferences, and personal situation.7
Monotherapy is preferred to treat patients with epilepsy. If a drug fails to work the diagnosis and patients’ adherence to their medication should be checked before trying an alternative treatment. If treatment with a single drug is still unsuccessful adding a second drug to the regimen can be tried.7
Some drugs, notably valproate and topiramate, have specific warnings associated with their use.
The Medicines and Healthcare products Regulatory Agency says that sodium valproate must not be prescribed for the first time in people (male or female) aged younger than 55 years unless two specialists independently agree and document that there is no other effective and tolerated treatment, or there are compelling reasons that the reproductive risks do not apply.8
Valproate can be prescribed to women and girls of childbearing age only if the conditions of the Pregnancy Prevention Programme are followed.
Under the programme pharmacists and dispensing staff must ‘discuss risks in pregnancy with female patients each time you dispense valproate medicines and ensure they have the Patient Guide and have seen their GP or specialist to discuss their treatment and the need for contraception’.
They must also ‘ensure new packs of valproate information materials are placed in a designated place accessible to all dispensing staff and dispose of any old materials related to valproate medicines’.8,9
Data from a study looking at medical records in Norway, Denmark and Sweden showed there was a small increased risk of neurodevelopmental disorders in babies born to women whose partner was taking valproate. So men taking valproate should use condoms and their female sexual partner should take contraception while valproate is being taken and for three months after the treatment has stopped.10
Topiramate should not be used to treat epilepsy in pregnancy unless there is no alternative and it should not be given to women of childbearing potential unless the Pregnancy Prevention Programme is followed. Contraception should be used during topiramate treatment and for four weeks after it finishes.
Women with epilepsy who are planning a pregnancy, or who become pregnant, while taking topiramate should consult their GP (urgently for those who become pregnant) but not stop taking their medication.11
Patients whose epilepsy is not controlled after two adequate trials of two well tolerated and appropriate drug treatment regimens (including combination therapy) are defined as having drug-resistant epilepsy by the International League Against Epilepsy.
These patients may need further assessment and treatment in a tertiary centre specialising in epilepsy. Other treatments such as ketogenic diet, cannabidiol, vagus nerve stimulation or surgery along with access to clinical trials can be offered.7