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|NI FEATURE: COMMENTARY: TIMELESS REVERBERATIONS
|Year : 2017 | Volume
| Issue : 7 | Page : 2-3
Epilepsy management-beyond prescription
Department of Neurology, Agadi Hospital and Sagar Hospital, Bangalore, Karnataka, India
|Date of Web Publication||8-Mar-2017|
H V Srinivas
Consultant Neurologist, Agadi Hospital and Sagar Hospital, Bangalore
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Srinivas H V. Epilepsy management-beyond prescription. Neurol India 2017;65, Suppl S1:2-3
Seizure management is critical and of prime importance in epilepsy, however, that is not the end of the story. Approximately 70–75% of persons with epilepsy (PWE) are seizure free with cost-effective primary antiepileptic drugs (AED). The diagnosis is entirely clinical; expensive investigations have to be requested judiciously and are required in a very few cases. Spontaneous remission without any AED has been observed in up to 30% PWE. When the primary medications fail, addition of clobazam, particularly in complex partial seizures, is effective. Home video recording of seizures on a mobile video has helped the clinicians in diagnosing not only genuine seizures but also the type of seizures.
There is a small but significant number (20–25%) of patients who do not respond to primary AEDs. In recent years, there has been an introduction of a steady stream of new antiepileptic drugs with the fond hope of addressing the “difficult to treat epilepsy.” However, it has been disappointing to note that none of them have bettered the antiepileptic effect of the primary drugs. Aggressive marketing as well frequent citing of side-effects of the primary drugs has resulted in the prescription of new and more expensive AEDs.
Advances in imaging, both structural and functional, and electrophysiology have remarkably improved the outcome of “drug resistant epilepsy” not only in magnetic resonance imaging (MRI) positive cases but also in MRI negative cases. Paradoxically, the advances in imaging and electrophysiological monitoring have also contributed to the over-diagnosis of generalized epilepsy. Any individual with a transient loss of consciousness (e.g., a person suffering from a syncope) is referred for electroencephalography (EEG) and imaging studies; and, even nonspecific abnormalities on EEG, and incidental findings on imaging (e.g., the incidental discovery of a calcified granuloma) are interpreted as being the “diagnostic” etiological factor responsible for the epilepsy.
Surgical treatment in patients with “drug resistant epilepsy” has a good outcome when these patients have been selected appropriately, resulting in a seizure-free state in 64–85% patients. While these achievements are laudable in controlling seizures, many more steps are required in the management of epilepsy.
A PWE is entirely normal between the seizures, and when seizures are well controlled, can lead a very normal life. With so much good news, why is the diagnosis of epilepsy being kept under wraps and discussed in “hush hush” tones? Why then is a PWE discriminated at every step of life – in education, sports, employment, marriage, etc. It is because the advances in our knowledge have not percolated to the lay persons, not even to the general medical community. The fault is with us neurologists, or shall I say general neurologists, because I find the specialized epileptologists are also involved in investigating and managing the cases of “drug resistant epilepsy.” In case a patient is suffering from hypertension or diabetes mellitus, the patient and the immediate family members need to be educated about the illness; while in the case of epilepsy, the entire society, including the doctors, need to be educated to integrate the PWE into the society, as well as to dispel the myths and stigmas attached to epilepsy. There is a huge treatment gap so that between 22% and 90% of the PWE in a particular area do not undergo treatment. This is largely due to the lack of public awareness, the stigma associated with epilepsy, the prolonged treatment required, the economic burden, and the nonavailability of drugs on a continuous basis.
One has to remember that diagnosis of epilepsy has far-reaching consequences not only for the patient but for the entire family. The psychosocial consequences and the comorbid conditions need to be addressed. In fact, epilepsy was a ground for divorce in the Hindu Marriage Act, until Indian Epilepsy Association, with the help and persistent efforts of stalwarts like Drs. K S Mani, P Bharucha, and their other colleagues, got it repealed in 1999. While the law has changed, the attitude of the people is yet to be changed. It is still widely believed both by lay people and the medical community that epilepsy is largely hereditary, and so the denial to undergo marriage with a PWE is not only focused on the person, but also on the fear of disseminating epilepsy to the next generation.
There is no significant change in the stigmas associated with epilepsy as well as the discrimination of a PWE, despite improvements in education and social parameters over the decades. To address these social issues, the Indian Epilepsy Association (IEA) was formed in 1970. Today, the IEA has 28 branches and a few of the chapters are actively pursuing the goals of IEA. Some associations have adopted villages, are conducting epilepsy camps, and are distributing free AEDs. Educating young minds in schools and colleges is of paramount importance, which a few chapters are pursuing.
To address various issues regarding the management of epilepsy at the National level, a National Epilepsy Control Program is envisaged with the objectives to promote public awareness; to dispel the myths, misconceptions, stigmas, and prejudices associated with epilepsy; to reduce the treatment gap; to ensure good management of epilepsy; and to initiate steps for the prevention of epilepsy.
While the social issues can be addressed by nonmedical persons (as in IEA), the medical issues have to be taken up by encouraging training of medical officers at various levels, as well as of medical students (both undergraduates and post graduates) for implementing the rational management of epilepsy.
A lot can be done to prevent epilepsy due to the presence of neurological infections (neurocysticercosis, neurotuberculosis), brain trauma (road traffic accidents), and birth injuries through adequate sanitation, public health education, and good antenatal care.
Finally, let us remember that the present day management of epilepsy is to administer symptomatic treatment, i.e., anti-seizure treatment that suppresses the symptoms of epilepsy. When the real antiepileptogenic drugs become a reality, they will focus on ameliorating the root cause of epilepsy as well as the epileptogenic focus, thus drastically changing the management of epilepsy – Development of anti-epileptogenic drugs will have an impact on the current practice of anti-epileptic medication as well as surgery for epilepsy.
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