Role of high-dose levetiracetam as add-on therapy for intractable epilepsy: case report and brief review of the literature.

CASE: We discuss the case of a 5-year-old long-standing epileptic woman, who received oxcarbazepine 2.1 g/day, and levetiracetam 3 g/day (started in 2005 and up-titrated according to response). In October/2008, due to poor seizure control, patient consent was obtained and levetiracetam up-titrated to 6 g/day, remaining invariable for 72 months; zonisamide was added in July/2009 and up-titrated to 500 mg/day. This combination achieved seizure frequency reduction ≥50 %, however, the patient ultimately necessitated temporal lobectomy for complete remission. Occasional agitation and moderate depression were the main side effects. CONCLUSION: Three anti-epileptic drugs (including levetiracetam 6 g/day) achieved statistically-significant seizure frequency reduction ≥50 % compared with lower doses, but not seizure freedom. Low-dose risperidone was initiated due to transient dose-dependent agitation, although it did not lead to discontinuation. This report provides insightful information on the use of high-dose levetiracetam in focal refractory epilepsy. The concomitance of anti-epileptics may have contributed to both efficacy and toxicity. Therefore, the risk/benefit ratio must be individually weighed until larger studies are available.

Do epilepsy specialist nurses use a similar history-taking process as consultant neurologists in the differential diagnosis of patients presenting with a first seizure?

The development of specialist nursing practice has blurred the boundaries between medicine and nursing. This mainly qualitative study compares the structure of epilepsy specialist nurse (ESN) and consultant neurologist (CN) clinical interviews at first seizure presentation and opinion on diagnosis. Twenty patients with a suspected first seizure were randomly allocated for clinical review with an ESN and then a CN, or vice versa. Clinical interviews were unstructured and audio-recorded. The ESN and CN reached an independent diagnosis for each patient. Audiotapes were transcribed verbatim. Emergent themes were identified, catalogued and grouped into major thematic areas. Annotated audio recordings, medical notes and dictated clinic letters were used to validate findings. Statistical analysis of inter-rater agreement of diagnosis was evaluated using Kappa. The clinical interviews of CN and ESN were similar in structure. Differences demonstrated CNs concentrated on the prodrome to events and expressed less diagnostic uncertainty. ESNs concentrated on post-ictal recovery and used more investigations. Complete disagreement on diagnosis occurred in 5 (25%) patients. Kappa score=0.510, demonstrating a moderate level of inter rater agreement on diagnosis between the CN and ESN.

The importance of brand continuity in epilepsy drugs.

Drugs are the mainstay of treatment for epilepsy, and are effective for most patients. However, minute differences between generic and branded drugs, and between different brands of the same drug, can affect epilepsy control. It is vital therefore that patients receive the same brand consistently to avoid loss of control.

A survey of a novel epilepsy clinic.

The management of a group of epilepsy patients from primary care, in a geographical area with clear epilepsy management guidelines and secondary care clinics is surveyed. Suggestions are made to improve liaison between primary and secondary care as well as epilepsy management in primary care. All 42 local primary care practices were invited to take part in this project. A study day providing a broad overview of epilepsy management was held. Those attending were expected to identify all patients in their practice with epilepsy using diagnostic codes and prescribing data. Nine of the invited 42 practices took part in the project, and identified 506 patients prescribed anti-epilepsy drugs (AEDs). Three hundred and three patients were invited for review by their practice nurse, following exclusion of those prescribed AEDs for other conditions, children and those already under specialist review. One hundred and sixteen patients attended for review. Seventy-one patients were identified as requiring specialist review and a consultant neurologist, epilepsy nurse specialist and clinical assistant completed them. Of the 71 patients 31 had experienced no seizures for 5 years, 40 had experienced seizures in the past 5 years, of whom 32 had experienced seizures in the last year. Sixteen were suffering at least one seizure per month, and a few had poorly controlled epilepsy. Patients were taking mainly Phenytoin, Carbamazepine and Sodium valproate. Twenty were taking polytherapy and one no treatment.Fifty-two patients reported side effects and 15 poor compliance. Many patients reviewed were considered to be taking unnecessary medication and suffering unnecessary side effects. There is a need for improved epilepsy management in primary care and better liaison between primary and secondary care.