Friday, May 25, 2018

Blog #94: DISAPPOINTING NEWS: NO IMPROVED SEIZURE CONTROL WITH NEW ANTIEPILEPTIC DRUGS OVER PAST 30 YEARS

A recently published study found that one-year seizure-free rates for epilepsy patients have hovered at 64 percent for 30 years. More than one-third of patients experience epilepsy that is uncontrolled.1 Seizure frequency has not greatly changed. Adding, or substituting, antiepileptic drugs (AED) did not significantly lead to complete seizure control.
For those patients who stayed seizure-free for a year, 87 percent were taking just one AED and 90 percent achieved freedom from seizures with either the first or the second AED. If the initial AED failed, the second and third regimens provided only an additional 12 percent and 4 percent likelihood, respectively, of seizure freedom. Reductions in seizure frequency for treatment-resistant patients on each new AED, however, are not insignificant. But, only 2 percent achieved optimal seizure control with subsequent AEDs.
Current AEDs do not modify the underlying cause, i.e., the pathobiology of epilepsy.
Most patients in the study initially took Carbamazepine (Tegretol), valproate (Depakote) and phenytoin (Dilantin) in the 1980’s and 1990’s. Later, levetiracetam (Keppra) and lamotrigine (Lamictal) were the initial AEDs. Although some newer drugs have novel anti-seizure mechanisms, they did not improve long-term seizure control.
Worse prognosis for control was associated with: a) the number of seizures that occurred prior to treatment; b) a family history of epilepsy in first-degree relatives and; c) a history of recreational drug use in epilepsy patients.
Research into interfering with or reversing the underlying seizure-inducing process, rather than just suppressing seizures, continues.
The secondary benefits of newer AEDs should be kept in mind compared with older AEDs: these include lower risks for birth defects, improved cognitive profiles and minimal drug interactions.
Newer drugs in the pipeline hold promise. Experience will reveal their efficacy.
Genetic manipulations and immune therapies are exciting research areas to improve or cure epilepsy.  
Epilepsy-surgery can be curative in properly selected patients.

  1. Chen Z, Brodie MJ, Liew D, et. al. Treatment outcomes in patients with newly diagnosed epilepsy treated with established and new antiepileptic drugs. A 30-year longitudinal cohort study. JAMA Neurology 2018; 75 (3): 279-286.


Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.

Tuesday, April 24, 2018

Blog #93: DRIVING AND EPILEPSY: COMPARING USA AND UK


            In the United States of America, only the states of California, Delaware, Nevada, New Jersey, Oregon, and Pennsylvania require physicians by law to report persons with epilepsy. California mandates physicians report such patients to the state health authorities. The health department then reports such persons to the Department of Motor Vehicles (DMV). The DMV obtains information on the person’s medical condition from the patient and from the physician. The DMV decides if the license is revoked for a period of observation. If the person remains seizure-free due to effective medications or because the epilepsy has become inactive for 6-24 months the driving privilege can be reinstated. The DMV makes this decisionnot the physician!

            If the driving privilege is reinstated but then another seizure occurs it’s the responsibility of the patient AND of the physician to report this to the DMV for re-evaluation.

            In the 44 American states that do not have a mandatory physician-reporting law, it’s up to the patient to voluntarily stop driving and to report to the DMV. Emotional constraints and ethical challenges are rife: who wants to stop driving if their livelihood depends on it and especially if there is a paucity of public transportation in their area? Some of my own patients challenged me: “Don’t send that report in, Doc. Are you going to pay my mortgage if I can’t work at my driving job?

            EPILEPSY ACTION, a website in the United Kingdom (England, Scotland, Wales and Northern Ireland), advises people who have had a seizure of any kind to stop driving and report their seizure-condition to the driving agency. 1 In the UK, unlike in the United States, reporting is not necessary “on the understanding if the seizures are nocturnal, i.e., the seizures occur only during sleep. In nocturnal-type seizures in the United States physicians in those six mandatory-reporting states still must report. But, physicians may support driving for these people by stressing that their seizures occur only during sleep and not while drivingnocturnal epilepsy. Sleep lowers the resistance on seizures in people with epilepsy.

            If one continues to drive in the UK they are breaking the law; significant financial fines can be levied. Car insurance is unlikely to cover the person.

            Personal responsibility, ethical behavior and common sense are challenged; abiding by the law often is abandoned as a part of our common humanity.

            My recent blog # 92 on this LanceFogan.com website (Citizens Influence New York State Law:Driving with Epilepsy, March 26, 2018) reviews how a deadly driving accident occurred during an apparent seizure in Brooklyn, NY in March, 2018. It led to a mandatory physician-reporting law being introduced in the New York State Legislature. If passed, New York would be the seventh American state making mandatory physician reporting of epilepsy. More lives then could be protected. 


1.    Epilepsy Action is a UK based charity providing information, advice and support for people with epilepsy. The organisation was founded in 1950 as the British Epilepsy Association and adopted Epilepsy Action as its working name in 2002. Epilepsyaction.org.



Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.

Tuesday, March 27, 2018

Blog #92: Citizens Influence New York State Law: Driving With Epilepsy

      A few weeks ago I saw a TV report: a Brooklyn driver ran a red light and killed two children, ages four years and one year old and injuring others, including a pregnant woman — “It was something you see in a horror movie,” a witness said. The car dragged one kid’s stroller more than 350 feet at Ninth St. and Fifth Ave. in Park Slope, Brooklyn, N.Y.
      According to reports, this auto accident was caused by a driver afflicted with multiple sclerosis, seizures and a heart condition. After the accident she said she didn’t recall the red light or hitting anything. On-sight witnesses reported that she seemed oblivious to what had just happened. That strongly suggests that this person’s epilepsy caused a seizure.
      Neurologists evaluate and treat people who experience altered and loss of consciousness.  In contrast to the epilepsy type that causes falling to the ground with convulsive shaking, I had to include the non-convulsive type epilepsy as a possible cause of a person’s altered behavior. This form of epilepsy can be difficult to recognize. The non-convulsive forms include complex partial seizures and petit mal seizures. People suffering these common forms of blank-outs may walk about, converse in a confused manner, turn on water faucets and eat at a table with other people all the while they are in a mental fog—out of contact with their environment and without memory of their actions.
      Children may suffer these seizures but teachers, families and even medical workers may miss the correct diagnosis. These people may be considered to be “slow learners,” or have hearing problems, attention-deficit disorders (ADD) or autism. The prime diagnostic tool, the electroencephalogram (EEG), commonly is normal because the epileptiform abnormalities may not occur in the brain during the hour or so that the person is connected to the brain-wave-detecting equipment. Brain scans routinely are normal, too. The diagnosis can be made by speaking with observers who note these patients’ “foggy” mind-states. My novel, DINGS, is a medical mystery story of just such a bright third-grader who is failing school because of his unrecognized complex partial seizure-blank outs. He’s just not “keeping up.”
      Upon seeing this report on TV two weeks ago I recognized Brooklyn’s Park Slope as a neighborhood in which my cousins live. I sent them my opinion that the driver must have had a seizure causing the accident of which she had no memory. “It was murder,” they told me.
     Why was this woman with epilepsy driving?
      I related that my state, California, is only one of six states where state law requires physicians to report people with altered consciousness. New York is not one of those six states. The other 44 states hope that people with epilepsy will report themselves to the Department of Motor Vehicles (DMV). That’s a problem. Some of my California epilepsy patients would become understandably belligerent when I would caution them of their driving responsibilities and to stop driving until sanctioned by the DMV; they were endangering their families, passengers, the public and themselves. “No, Doc. Don’t send that report in. Are you going to pay my mortgage?” Personal insight, personal economics and ethics all swarm in their minds as they make decisions of giving up their driving privilege, i.e., their DMV license.
     Upon learning my information my Brooklyn cousin asked if he could share it with a New York State legislator’s office. That same week Brooklyn State legislators unveiled a bill to create a mandatory reporting system and to authorize the DMV to evaluate pe  I shall be following New York’s action.


Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.

Monday, February 26, 2018

Blog #91: Non-Drug Treatments for Epilepsy



            Many patients whose epilepsy responds poorly to antiseizure medications (20-30% of the three million American epilepsy population) may benefit from non-drug treatments. A study presented at the 71st American Epilepsy Society Annual Meeting showed evidence that Vagus Nerve Stimulation (VNS), the ketogenic diet and a surgical procedurecorpus callosotomymay reduce generalized and focal seizures. Among patients who failed three anticonvulsive medications between ages 8 months to 20 years, with a mean age of 10 years, underwent one of these treatments. Most of the patients’ parents were pleased with the results.1 Sixty-three percent of patients who went on the ketogenic diet reported 50% or greater  reduction of their  generalized seizures. Fifty-four percent of patients who underwent corpus callosotomy and 52% of patients who received vagus nerve stimulation reported 50% or greater reduction in their generalized seizures.

            A very important benefit in withdrawing multiple anticonvulsive medications is that drug side effects are minimized: drowsiness, poor concentration, weight control problems, blood testing, teratogenic risks for women among other effects.

  • Vagus Nerve Stimulation is sometimes referred to as a "pacemaker for the brain." A stimulator device is implanted under the skin in the chest. A wire from the device is wound around the vagus nerve in the neck. A person with a VNS device is usually not aware it's operating.

  • The ketogenic diet is a special high-fat, low-carbohydrate diet that helps to control seizures in some people with epilepsy. It is prescribed by a physician and carefully monitored by a dietitian. It is extremely strict, with calorie, fluid, and protein measurements. Ketones are formed when the body uses fat for its source of energy. The body usually uses carbohydrates (such as sugar, bread, pasta) for its fuel, but because the ketogenic diet is very low in carbohydrates, fats become the primary fuel instead. Higher ketone levels often lead to improved seizure control but the precise reason is not understood.

  • Corpus callosotomy The corpus callosum is the most important connection between the two halves of the brain. Callosal surgical sectioning is quite effective in reducing seizure frequency in patients who have generalized epilepsy with drop attacks. It is generally reserved for this selected population. It is an epilepsy surgery procedure that is considered palliative only. It mediates communication between the two hemispheres of the brain. Seizures may spread rapidly from one hemisphere to the other by way of the corpus callosum; thus seizure spread is reduced and control is increased.  Serious complications are exceedingly rare.

            Dr. Dave Clarke, Clinical Director of Epilepsy at Texas Children’s Hospital at the Baylor College of Medicine in Houston led a study with colleagues at the Dell Children’s Medical Center in Austin between January 2010 and November 2015. They compared seizure control, cognitive and behavioral factors, quality of life and parental satisfaction.

            Parents reported a 50%, or greater, reduction in generalized seizures in 63% of patients who went on the ketogenic diet, 54% of patients improved who underwent corpus callosotomy and 52% of patients improved who received VNS.

            “Many doctors keep trying medications without considering alternatives,” said Dr. Clarke. He suggests doctors introduce treatment alternatives after two anticonvulsive medications fail to control seizures.


1.      www.neurologyreviews.com: Jack Remaly in Neurology Reviews. January 2018, page 1, 45-46.




Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.