Epilepsy: Treatment Strategies for Epilepsy
Transcript:
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.