This interview was conducted in the office of Professor Nazir. Panel Consisted of Dr Mohammad Nawaz Ghumman; Capt Dr Liaqat Ali, Dr Mehboob Ashraf and Dr Saleem Rana. Following comments were made in response to multiple questions of panelists. Questions are being omitted. If there is any inconsistency or inappropriate remark, this is due to error in reporting.
Knowledge of subject and proper history makes a family physician expert in Epilepsy.Not much examination is usually involved. Diagnosis is often based upon history alone. If proper drugs are prescribed, following established prinicipals, patients can benefit by the expertise of family physicians at their doorstep.
Short Comings of Family physicians.
(These comments were specifically invited)
v Diagnosis is often lacking.Type of epilepsy is being ignored.
v Multiple drugs are being used without proper indications.
v Dosage is open to severe criticism. Prinicipal in epilepsy is opposite to many other systems like infections. Antibiotics are prescribed in full and maximum dosage in beginning. But in epilepsy each drug must be started in lowest possible dose. It should be gradually increased till the controll is achieved. Increments should be at weekly intervals. Second drug should be introduced only when maximum dose of first drug is achieved. Minimum possible dose and least possible number of drugs should be used. It will improve not only the control but compliance also. Cost, which is so important in our conditions, can be kept low and must be kept low.
Principle to be followed is
from low to high dose, not vice a versa.
It can take 6-8 weeks to set the dosage.
v Difference between adult patients and paediatric patients.
All considerations and specifications of diagnosis, prognosis, drugs and all others are common in all age groups. So any knowledge applied to paediatric patiens can be applied to adult patients.
Only difference is this. There are more types and varieties of epilepsy found in childern than in adults.
Diagnosis of Epilepsy
It is mainly clinical, based upon history. Proper application of adequate knowledge is all that is usually required. Questions to be defined are followings.
v Is it really Epilepsy? Description of fit may not be typical.
v What is the type? This is very important. As further management is based upon this typing.
v Best drugs for different types are different.
Investigations.
EEG
This is basic investigation. Much more important than CT scan. EEG is not exclusive. If it is normal, that does not mean that Epilepsy is excluded from diagnosis. EEG may be normal in Epilepsy.
It is positive in 70 % of paediatric patients of Epilepsy.While in adults it is positive in 50 % of patients.
It is also helpful in differentiating different types.
Indications for EEG.
If patient can afford, It should be ordered in all patients as a routine investigation. But it is not essential for diagnosis or starting treatment. Diagnosis can be made without it and treatment can be started.
More important is to get it done before stopping the therapy at end of fit free interval of 2-3 years. Because if there is some abnormality then treatment must not be stopped there.
CT scan is positive in only 30 % of patients and is being wrongly prefered.
CBC and LFTs are mainly ordered to monitor the side effects.
Inheritance
Hereditory factors play definite role, in relatively less number of patients. Inheritance has not been defined yet.
Management of First episode of Convultions.
50 % of cases do not have 2nd episode throughout their life. So it is advisible not to start any therapy after first episode. Just wait. If there is second episode only then start treatment.
Management of Febrile convultions.
Important figures to remember are that only 30 % of patients having febrile convultions will have fits again during future episodes of fever.70 % of children will never have convultions again even during fever.
Only 2-12 % of such children will progress to epilepsy.
In view of above-mentioned figures, rational approach would be this.
After first episode of febrile fits, nothing should be done.
Treatment may not be needed even if 2 or 3 fits have occured. However in case of more fits or younger age, less than 2 years, when recurrence chances are high oral Valium may be started. Dose is 0.3 mgs /kg tid for 3 days. It should be started as soon as fever is noticed.
Management during attack of Convultions.
Primary need is prevention of Asphyxia.
1. Lie down the patient on side.Extend the head.Open up any buttons or loosen the neck.Clear the secretions from mouth.Keep open and clear respiratory passages
2. Give intravenous Valium slowly over 4-5 minutes. Fast intravenous adminiserations can produce shock or respiratory arrest. Intramuscular Valium is of no immediate benefit. Per rectum administeration by a catheter can be as effective as intravenou route.
3. To prevent hypoglycaemia 5 % dextrose drip can be started.
Life time cure.
If patient can be kept fit free for 2-3 years, 70 % chance of lifetime cure is there. Only 30 % of these patients have recurrences.
After fit free interval treatment should be tailored of over 4-6 months gradually.
EEG is almost essential before stopping the treatment. If there is any abnormality, then treatment should be continued even if there is no fit.
Convultions secondary to CNS infections
Menengitis, Encephalitis and brain abcesses in addition to other space occupying lesions are associated with convultions. Anticonvulsive therapy should be continued for 4-6 weeks after the infection and convultions are controlled. Majority of patients does not have recurrences.
Anti convulsive therapy.
In our society we must keep following points in mind for best compliance.
1. Drug should be cheap
2. It should be once a day preferably.
3. In twice daily dosing interval between two doses must not exceed 12 hours.
4. Drug should be the best for the type of epilepsy.
5. Side effects in specific groups should be considered before prescribing drugs.
Commonest varieties.
Two types are most common.
1. Generalized tonic clonic contractions.
2. Complex partial siezures.
Following 4 drugs are equally effective in these two varieties.
1. Phenobarbitone
2. Phenytoin
3. Tegretal
4. Valproic acid
Phenobarbitone and phenytoin are cheapest and once daily dosage.
Tegretal and Valpraote have twice daily dosage and are expensive
Important Side effects profile.
v Phenobarbitone causes drowisiness and can be avoided in school going children, if at all, they are going to school. Nighttime dose should be prefered.
v Phenytoin causes gums hypertrophy and ataxia, can be avoided in girls.
v Rash is common with tegretal and valproate. These may cause hepatic damage.
v If a child, who is on phenobarbitone and becomes irritabe, dose should be lowered or drug should be terminated.
v Valium is not recommended for long term use.
v Rivotril: This drug is rapidly effective almost in all types. This is second line drug and used only in those patients who are not being controlled on other drugs. Tolerance develops rapidly. In children it should be avoided as it increases secretions. Important drawback is that it has to be given 6-8 hourly.