A new FREE course for Pharmasists worth 2 CE credits that focusses on partial-onset seizures just became available through Pharmacy Times.
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|A Pharmacist-Focused Review on Epilepsy: Improving Treatment Outcomes in Partial-Onset Seizures||Details | Lesson | Questions | Take Test|
Excerpt from Lesson:
Numerous antiepileptic drugs (AEDs) have entered the market, but nearly one-third of patients with epilepsy have refractory seizures. This review will examine the use of newer and more established agents with regard to their place in therapy, adverse effects, and drug interaction profiles in the context of the role of the pharmacist to optimize care.
Epileptic seizures are defined as a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain. The seizures can affect 1 or more of the following: sensory, motor or autonomic function, consciousness, emotional state, memory, cognition, or behavior. Presentation of the seizures depends on the location of onset in the affected individual’s brain, comorbid diseases, concurrent medications, sleep-wake cycle, and other factors. In contrast, epilepsy requires the occurrence of at least 1 epileptic seizure, and is characterized by an enduring predisposition to generate epileptic seizures, and by the neurobiologic, cognitive, psychological, and social consequences of the condition.1 Consequently, persons with epilepsy have a predisposition to seizures, a history of seizures, and an enduring alteration in the brain.1 Because epilepsy is a brain disorder affecting nearly 2 million persons in the United States and about 45 to 50 million worldwide, it is one of the more common serious neurologic disorders.2-4 The prevalence is about 0.5-1% worldwide, with an annual incidence which is higher in developing countries (190 per 100,000) than industrialized countries (50-70 cases per 100,000). About 5% of the world population experiences at least 1 lifetime seizure, excluding those with febrile seizures.4
Epilepsy classification criteria proposed by the International League Against Epilepsy (ILAE) were updated in 1981, revised in 1989, and upheld in 2006.5-7 According to the classification, epilepsy is characterized according to category, defined by onset features, and etiology. The 2 major categories of epilepsy are generalized and partial.
Generalized seizures usually involve both hemispheres of the brain and involve bilateral motor involvement and loss of consciousness. The motor symptoms vary depending on the type of generalized seizure. Some types of generalized seizures are absence, tonic-clonic, and myoclonic. In contrast, partial (focal) seizures are characterized as simple partial, complex partial, and partial evolving to secondarily generalized. These partial seizures originate in 1 hemisphere of the brain, and can lead to disturbances in motor function, sensory perception, behavior or autonomic function.5 Partial seizures are far more common in new-onset epilepsy (approximately 70% of cases) than other types of seizures. Simple partial seizures have no loss of consciousness, and complex partial seizures are associated with loss of consciousness. New onset seizures are usually caused by unknown causes (62%), but stroke (9%), head trauma (9%), alcohol (6%), neurodegenerative disease (4%), and other factors, such as genetics, also contribute to the etiology.2
Whatever the cause and presentation, seizures occur during an imbalance of excitatory and inhibitor neurotransmitters in the central nervous system. Increased neuronal excitability due to changes in voltage-gated ion channels including sodium and calcium, or ligand-gated glutamate neurotransmitters, or decreased inhibitory ligand-gated gamma-aminobutyric-acid (GABA) neurotransmitters, along with excessive acetylcholine, norepinephrine, and serotonin inhibitory channels, lead to seizure development.3 Many of the pharmacologic agents used for epilepsy target these mechanisms, but about 30% of patients exhibit resistance to medication, and there are long-term adverse consequences of epilepsy. Seizure severity and changes in seizure severity have been attributed to alterations in quality of life (QOL) in patients with epilepsy. Evaluation of instruments, such as The Quality of Life in Epilepsy-31 (QOLIE-31) tool during treatment success and treatment failure, has demonstrated that seizure severity correlates significantly with anxiety, seizure worry, social functioning, cognitive status, and overall QOL.8,9 These QOL studies also demonstrated prevalence of depression and an important role of the depression in the patient QOL status.8 Conversely, improving seizure severity and frequency in patients with partial epilepsy, through use of effective medication, can improve QOL.9 Medications for epilepsy are primarily evaluated for efficacy based on the ability to reduce the frequency of seizures.10
In addition to improvements in QOL, another reason to improve control of seizures in patients with epilepsy is to reduce the risk of death. Sudden unexpected death in epilepsy (SUDEP) occurs with an annual incidence of 0 to 10 per 1000 patients, depending on the presence or absence of risk factors. Strong risk factors include younger age, high seizure frequency, high number of AEDs, long duration of epilepsy, and concurrent psychotropic medications when using live patients as controls. When using non-SUDEP deaths as controls, younger patients, seizure preceding death, patient found in bed, and subtherapeutic drug levels were risk factors.11
Due to the importance of epilepsy as a significant neurologic illness, and the important impact on QOL and mortality in affected patients, this review has briefly discussed the epidemiology and pathophysiology of various types of seizures in epilepsy. Because partial seizures are far more common than generalized seizures, this article will focus on the management of epilepsy with partial-onset seizures in the context of newly emerging AEDs in treatment-refractory partial-onset seizures. The article will also address the pharmacist’s role in managing these patients, including counseling and managing complications such as adverse effects and drug-drug interactions.