Should anticonvulsants be recommended for a patient without prior seizures who presents with multiple seizures within a 24-hour period? In a recent publication, Lay Kun Kho et al addressed this specific question, and "sought to define the clinical features and prognosis of adult first-ever seizure patients presenting with two or more discrete seizures within 24 hours" ( Neurology 2006 67:1047-9). The investigators compared the clinical features and prognosis of 72 adults with first time ever multiple discreet seizures within 24 hours to 425 patients presenting with a single seizure. They concluded that patients presenting with multiple seizures within a 24-hour period were no more likely to have seizure recurrence within one year than those with a single seizure (see also the commentary by Carl Bazil, MD, PhD, and Alan Hauser, MD, PhD, in the same issue (Neurology 2006; 67:947))
How do these new data impact the decision on when to start an anticonvulsant? We asked two experts.
COMMENTS OF EPILEPSY EXPERTS
Dieter Schmidt, MD, is currently Emeritus Professor of Neurology at the Free University of Berlin, Germany and head of the Epilepsy Research Group (ERG), Berlin. Professor Schmidt is a graduate of the Heidelberg Medical School and trained with Professor Dieter Janz in Berlin, before becoming Chairman and Professor of the Department of Neurology, Klinikum Charlottenburg, at the Free University. He received the Ambassador for Epilepsy award from the International League Against Epilepsy in 1983, and is a corresponding member of the American Neurological Association. He was appointed Head of the ERG in Berlin on his retirement from the Free University. Professor Schmidt was one of the founding editors of Epilepsy Research. His areas of special interest include the pharmacologic treatment of epilepsy and the methodology of clinical trials in epilepsy and other chronic neurologic disorders. In addition, Professor Schmidt acts as a consultant for various European regulatory agencies, offering his expertise in the treatment of neurologic disorders.
Mark C. Spitz, MD, a graduate of the University of Arizona, College of Medicine, has been affiliated with the University of Colorado Health Sciences Center since 1985 where he is currently a professor in the Department of Neurology. Dr. Spitz is board certified in neurology and clinical neurophysiology and is a fellow of the American Academy of Neurology. He is a member of several professional and scientific societies, including the American Clinical Neurophysiology Society, and the American Epilepsy Society, where he serves on the technology committee. Dr. Spitz has received industry-sponsored grants to conduct drug treatment trials in different types of epilepsy. In 2003, he won the Commitment to Medical Excellence in Epilepsy Award from the Epilepsy Foundation of Colorado. He is on the editorial board for Epilepsy.com, and has authored or coauthored 22 peer-reviewed publications, 52 abstracts, 13 invited publications and book chapters which largely concern the diagnosis and treatment of various forms of epilepsy.
How will this study impact your treatment decisions regarding when to start anti-consultants?
Mark Spitz: As a neurologist and epileptologist, when I am left with a decision as to whether or not I give an antiepileptic drug to someone who is facing seizures -- I weigh the risks and the benefits. The benefit is that it minimizes the chance of recurrence, whereas the risks include the side effects, the nuisance of staying on medication, and the problems that ensue once you decide to discontinue.
Dieter Schmidt: For me, no change. This study further assures me that I do not need to change my policy when to start antiepileptic drug treatment.
Mark Spitz: I will change my policy, because in the past, when I saw a patient who had two seizures within a 24-hour period, I would have started them on a medication. Now it is unlikely that I will do so.
What other factors go into your decision?
Dieter Schmidt: The decision to start treatment after one seizure is primarily based on long-term recurrence risk and the patient's preference.
Mark Spitz: Many risk factors help a physician decide whether or not to begin treatment as I have already stated. But there are also psychosocial reasons that play a role in decision-making. For example, there are different considerations with regard to a woman who wants to start a family. This might indicate reasons not to start AEDs.
In contrast, if a person has an active lifestyle and engages in activities that are dangerous, or possibly embarrassing to them if a seizure occurred, that person might be more eager to start a medication.
Dieter Schmidt: I fully agree: do what the patient wants and individualize your decision as much as possible. You do not want to decline treatment in a patient who wishes to start and would not insist on treatment if the patient is inclined to wait for another seizure.
In your practice does initiation of antiepileptic drug therapy require a diagnosis of epilepsy?
Mark Spitz: Without a specific diagnosis of epilepsy, for example if patient has an episode of alteration of consciousness and it is unclear as to why, a trial of an AED is not an appropriate diagnostic tool.
Dieter Schmidt: In most cases, yes. Only when a patient insists will I treat after one seizure. The main reason why patients start treatment after one seizure is that they fear that a second seizure will impair their ability to legally drive a car for some time. Secondly, they want to protect themselves from social stigma and embarrassment from a second seizure.
Mark Spitz: In the United States, the standard of care in treatment of a single unprovoked seizure is different than in Europe. Here many physicians will treat a single seizure, whereas in Europe, it is done more infrequently.
If you are considering antiepileptic drug therapy, what are your considerations with regard to the risks of further seizures against the risks of starting on AED?
Dieter Schmidt: You wish to minimize the risk of treatment. My main consideration is to pick an efficacious AED that is not involved in drug interactions and does not cause idiosyncratic skin reactions or weight gain. You want to make sure that the patient understands what current AEDs can do and what they cannot do. AEDs block seizures and yet do not seem to impact on the seizure outcome of the epilepsy. Early use after one seizure does not protect against developing drug resistance. Also, when no further seizures occur, there is an uncertainty of how long you wish to treat: for 6 months, 1 years, 2 years or 5 years?
Mark Spitz: I take into consideration the risk of recurring seizures, the risk of starting a medication, along with the side effects, cost, nuisance, and dilemma of when and if to discontinue. Furthermore there are issues such as the need to stop driving when one comes off the medication, which is a social issue that needs to be considered.
One of the key points for early relapse is whether the patience has had two seizures. If so, the risk of recurrence is 80 percent more – therefore, you would be more likely to begin instituting AEDs. With this new data, however, if the two seizures occur within a 24-hour period, it appears that there is a much smaller percentage with regard to risk. This will make a significant difference in my own practice, unless the patient has a first degree relative with epilepsy, in which case I believe the odds of seizure recurrence are higher, and I might be inclined to recommend an AED.
Dieter Schmidt: No further comment.