Epilepsy: Treatment Strategies for Epilepsy

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Epilepsy:  Treatment Strategies for Epilepsy




Guest:  Dr. Jonathan Edwards - Neurosciences

Host:  Dr. Linda Austin – Psychiatry


Dr. Linda Austin:  I’m Dr. Linda Austin.  I’m talking, today, with Dr. Jonathan Edwards who is Director of the Comprehensive Epilepsy Program and Associate Professor of Neurology here at the Medical University of South Carolina.  Dr. Edwards, we’ve been talking about the diagnostic workup for epilepsy.  Let’s turn now and talk about treatment strategies.  Let’s start with adolescents.  How do you think about what the treatment options are for a teenager, a kid, who’s newly diagnosed with epilepsy?


Dr. Jonathan Edwards:  When it comes to treating seizures, it certainly is not a case of one size fits all.  You really need to take into consideration the most important issues for that patient.  There are certain medications that work very well for a particular type of epilepsy and maybe worthless for another type of epilepsy, and vice versa.  Additionally, at different parts of life there are certain issues that are very important.  There are certain medications that carry with them big concerns when it comes to reproductive issues or potentially causing birth defects, which are a very big issue to a young woman, maybe less of an issue to an elderly man. 


On the other hand, there are certain patients for whom their biggest concern may be that they do not want to take any medication that could slow them down at all, and certain medications are more sedating than others.  For other patients, the most important thing to them may be taking the medication that is the most likely to make them seizure-free as fast as possible.  So, different patients have different concerns, and the only way to know the most important thing is to talk to your patient and see what’s most important to them.  Then you discuss the advantages and disadvantages of the various treatment options.


Dr. Linda Austin:  I believe I’m right in thinking that the oldest of these medications is Dilantin.  Was that the first?


Dr. Jonathan Edwards:  The very oldest that we widely use now is Phenobarbital.


Dr. Linda Austin:  Phenobarb?


Dr. Jonathan:  Then Dilantin came out in the 1930s.


Dr. Linda Austin:  Now, are those two meds still used?


Dr. Jonathan Edwards:  They are still used, yes.


Dr. Linda Austin:  But they’ve been supplanted by many others, is that right?


Dr. Jonathan Edwards:  Yes.  The two medications are still used but they do carry with them a lot of baggage, if you will.  They have a lot of downsides.  Phenobarbital is a barbiturate and it can be sedating.  In fact, in young children, it can sometimes cause severe behavioral problems and hyperactivity.  Dilantin is a very effective medication.  It’s been around, now, for decades.  And it has treated us relatively well in terms of helping a lot of patients get control of their seizures.  But it has a lot of side effects, both long-term and short-term, that have made it start to fall out of favor quite a bit now that we have some new alternatives.


Dr. Linda Austin:  And there are lots of new alternatives, right? 


Dr. Jonathan:  Oh, yes. 


Dr. Linda Austin:  Too many, maybe, to mention in a podcast.


Dr. Jonathan Edwards:  We have about 15 different widely used seizure medications now, which is a wonderful advantage compared to what we had 20 years ago.


Dr. Linda Austin:  So, when you start treating a patient, how often do you get it right?  Do you get lucky with the first choice versus maybe having to do some trial and error and try different medications?


Dr. Jonathan:  That’s a great question.  If you take all patients with seizures, the chances of getting control of the seizures with the first drug is actually about 50/50, with the very first drug you try.  But with each medication failure, the chance of getting control with the next drug gets lower and lower.


Dr. Linda Austin:  So, it’s very much like my field, psychiatry.  When we treat depression, I would say that those statistics are probably, maybe, about the same too. 


Dr. Jonathan Edwards:  They’re very similar.


Dr. Linda Austin:  You don’t always get lucky the first time.  And you can’t always just predict by talking to a patient.


Dr. Jonathan:  You can’t.


Dr. Linda Austin:  So, if you try a first medication and, let’s say, that helps somewhat but not completely, do you typically jump ship and try a second one, or do you add on a second one?


Dr. Jonathan Edwards:  Well, if we tried that medication and got to the point where the patient says, I’m having side effects and I would like to change medication, or it just doesn’t work, no matter how much of it we use, then I will typically switch to a different medication and use that other medication by itself.  It’s always a good idea to try to get someone on as few medications as possible.


Dr. Linda Austin:  Are the meds you use for teenagers usually the same as for adults?


Dr. Jonathan Edwards:  Yes, for the most part.


Dr. Linda Austin:  And does the cause of the seizure matter?  The location of the seizure matters, right?


Dr. Jonathan Edwards:  The type of the epilepsy matters.  For example, there’s one type of epilepsy called primary generalized epilepsy (PGE).  It tends to respond very well to a certain category of medications.  And then there’s another type of epilepsy

called focal or partial epilepsy, and those types of epilepsy may respond to other medications.  And what’s nice is that we now have some broad spectrum agents that work for both focal and generalized epilepsy.


Dr. Linda Austin:  Now, in my field, sometimes I’ll find myself using several medications in lower doses to try to get away from side effects, and patients, sometimes, end up feeling like they’re on a lot of different pills when, actually, the load on their body may be less because the dosage is lower.  Is that ever true in your field too?


Dr. Jonathan:  We do, sometimes, use combinations of medications.


Dr. Linda Austin:  In order to achieve a better result?


Dr. Jonathan Edwards:  Yes.


Dr. Linda Austin:  Are there situations, though, where it just seems like no matter what you do, no matter how many different medications you try, you can’t get control?


Dr. Jonathan Edwards:  Yes. Our currently available seizure medications will help us gain complete seizure control for about two thirds of our patients that live with epilepsy.  Now, two thirds is good, but that still leaves us with one third of our patients whose seizures are not adequately controlled with the currently available medications.


Dr. Linda Austin:  And, what do you do for those folks?


Dr. Jonathan Edwards:  Well, for those patients there, still, are several options.  Just because the medications don’t work, it doesn’t mean that they should give up hope.  There are many options for those patients.  One of the things that we look towards, for those patients, is curative epilepsy surgery.  With epilepsy surgery, the goal is, find the part of the brain that the seizures are coming from, and then we figure out what that part of the brain is actually doing.  Then the goal is to move forward with surgery to remove that part of the brain to get rid of the seizures completely.  And epilepsy surgery is an option for, probably, about a third of our patients, for whom the medications have not given them adequate control.


Dr. Linda Austin:  Is that type of surgery available at MUSC?


Dr. Jonathan Edwards:  Yes, it is.


Dr. Linda Austin:  How wonderful to know that those options are available.


Dr. Jonathan Edwards:  It’s extremely gratifying.


Dr. Linda Austin:  How about any other new techniques for treating epilepsy?


Dr. Jonathan Edwards:  Well, in addition to surgery and medications, there are dietary interventions.  One is called the ketogenic diet, and then there are modified versions of that.  Then there are neurostimulators.  There’s one called a vagus nerve stimulator, which helps reduce seizures.  And then there are other newer techniques that are under investigation right now that we are also using here at MUSC.


Dr. Linda Austin:  Well, let’s talk about those in another podcast.  Thanks a lot, Dr. Edwards.


Dr. Jonathan Edwards:  Thank you.


If you have any questions about the services or programs offered at the Medical University of South Carolina or if you would like to schedule an appointment with one of our physicians, please call MUSC Health Connection:  (843) 792-1414.


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