Diagnosing and managing epilepsy
NICE has updated its guideline on epilepsy, mainly because new drugs have been licensed to prevent variations in care.
The National Institute of Health and Clinical Excellence has updated the pharmacological recommendations from its 2004 clinical guideline on diagnosing and managing the condition (NICE, 2012). The main aim of the guideline is to assist practitioners and help to inform patients’ decisions about the treatments and care they should receive from the NHS.
Epilepsy is characterised by recurrent seizures unprovoked by any immediately identifiable cause. An epileptic seizure is the clinical manifestation of an abnormal and excessive discharge of a set of neurons in the brain.
The main goal of epilepsy management is seizure control, but this should not be at the expense of excessive side-effects. NICE advises that the choice of anti-epileptic drug (AED) should be tailored to individual needs and be based on evidence.
Since the original guideline was issued in 2004, four new AEDs have been licensed. Policies on when, how and in what order they should be considered vary across the NHS, and both prescribers and non-prescribers should know which AEDs are clinically and cost effective for different types of epilepsy syndrome and seizure, and for particular patient groups, such as older people and pregnant and breastfeeding women.
Health professionals need to be aware what advice they should give about AED use in specific circumstances, for example in pregnancy, alongside contraception and for people with learning disabilities.
Below are some of the main changes to the guideline.
Choosing which AED to offer should be based on the presenting syndrome or, if this is not known, the seizure type.
A consistent supply of a particular AED preparation is recommended, unless the prescriber, in consultation with the person affected, considers that this not a concern.
When prescribing sodium valproate to girls and women of childbearing age, practitioners should discuss the possible risk of foetal malformations and neuro-developmental impairments, particularly if the dosage is high.
Prescribers should consult with the Summary of Product Characteristics (SPC) and the British National Formulary (BNF) when prescribing AEDs for women who are breastfeeding. The choice of AED should be made jointly by the woman and the prescriber, and the decision should be based on the risks and benefits of breastfeeding against the potential risk of the drug affecting the child.
When considering cost - particularly given the requirement to prescribe generic drugs wherever possible - the guideline reminds nurses that “different preparations of the same AEDs may vary in bioavailability or pharmacokinetic profiles and care needs to be taken to avoid reduced effect or excessive side-effects”. Nurses are advised to refer to the SPC and BNF on the bioavailability and pharmacokinetic profiles of individual AEDs.
The guideline recommends carbamazepine or lamotrigine as first-line treatments for children, young people and adults with newly diagnosed focal seizures. If these prove unsuitable or are not tolerated, it suggests oxcarbazepine, sodium valproate or levetiracetam.
NICE provides guidance on the pharmacological management of different epilepsies including familiar and more complex syndromes. For syndromes such as Dravet and infantile spasms, it advises professionals to refer to or discuss these patients with tertiary paediatric epilepsy specialists.
For other epilepsy syndromes and seizure types, the guideline advises on which AEDs to offer first and what to consider if the first drug is inappropriate, ineffective or has excessive side-effects.
The guideline continues to recommend monotherapies as first-line treatment. Where this is not effective, it provides the best evidence on which AEDs should be considered for use as adjunctive therapies.
Health and safety
Health professionals should look out for adverse effects from treatments (for example bone health and neuropsychiatric issues). They should also be aware of the risks in prescribing sodium valproate to girls or women of childbearing age.
Managing prolonged or repeated seizures in the community
Buccal midazolam should be administered as the first-line treatment. Rectal diazepam should be considered where it is preferred, or when buccal midazolam is not available. Buccal midazolam and rectal diazepam should be prescribed when patients have had previous episodes of prolonged or serial convulsive seizures.
Tracey Truscott is an independent non-medical prescriber, head of epilepsy nursing services and clinical nurse specialist for epilepsy at Kent Community Health Trust, and a member of the NICE guideline development group.
An exclusive summary of new NICE guidance from a member of the guideline development group.
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National Institute for Health and Clinical Excellence (2012) The Epilepsies: the Diagnosis and Management of the Epilepsies in Adults and Children in Primary and Secondary Care. London: NICE.