Blog #80: How Epilepsy Patients Use Herbal and Botanical Therapies

            In NEUROLOGY NOW, February, 2017, page 12, Dr. Dana Ekstein, senior neurologist at Hadassah Medical Center in Jerusalem, reviewed the use of non-prescribed chemicals and herbs that epilepsy patients use to help control seizures, to treat medication side effects, and to treat their anxiety, depression and memory problems.

            A 2012 American Health Interview Survey revealed about eighteen percent of the American population use complementary herbal and botanical medicines other than vitamins, and nonmineral natural products. Among people with epilepsy half of adults and a third of children use complementary therapies without their physicians’ knowledge. Some of these botanicals interfere with their prescribed antiseizure medications.

 

            Another study, a Canadian study ¹, found that fifty-nine percent of patients with epilepsy and thirty-three percent of patients with psychogenic non-epileptic seizures (see my Blog #10: September 23, 2011 Is It A True Epileptic Seizure or a Faked, Psychogenic Seizure With a Psychological Cause?) who participated in the study and who used cannabis, i.e., marijuana, hashish, “pot,” etc., daily perceived improvements in seizure control, stress, sleep quality, and drug side effects. Although their perceived stress reduction may have contributed to the perceived positive impact of marijuana on seizures and nonepileptic events in adults, the researchers reported that they could not reliably conclude that Cannabis was objectively efficacious.

            A Cochrane Review (Cochrane works collaboratively with contributors around the world to produce authoritative, relevant, and reliable evidence in the form of Cochrane Reviews) of cannabinoids for epilepsy found no reliable conclusions could be drawn regarding the efficacy of the studied doses of 200-300 mg daily of cannabidiol component of the marijuana plant (the non-psychoactive component of marijuana plants in contrast to the psychoactive tetrahydrocannabinol [THC] component) ². Further trials are needed in this area.     

            Another trial led by Devinsky et al ³ concluded that of 137 patients with onset of drug-resistant epilepsy beginning in childhood and currently experiencing at least four seizures per month, thirty-nine percent enjoyed a fifty percent, or greater, reduction in seizure frequency.

            Regarding the treatment of depression in epilepsy with botanicals a Chinese mushroom called Xylaria nigripes was studied in a random, double-blind, placebo-controlled trial of one hundred four patients. The mushroom-treated patients reported significantly improved depression and quality of life scores compared with placebo ⁴.

           One must use caution in assuming that natural products are safe. Ephedra, St. John’s wort and ginkgo biloba can cause seizures. Tetrahydrocannabinol [THC] may impair memory and executive function and induce psychiatric symptoms. Other unwanted side-effects in cannabis trials include worsening seizures, drowsiness, fatigue, and gastrointestinal complaints. 

            Interactions s between antiseizure drugs and botanicals can include altered blood levels of the antiseizure drugs (cannabidiol increases concentrations of clobazam).

            Dr. Eckstein emphasizes that neurologists need to be well-educated and up-to-date regarding botanical therapies.

1)    Massot-Tamis A, McLachlan RS. Marijuana use in adults admitted to a Canadian epilepsy monitoring unit. Epilepsy Behav. 2016; 63: 73-78.

2)    Gloss D, Vickrey B. Cannabinoids for epilepsy. Cochrane Database of Systematic Reviews 2012, Issue 6. Art. No.: CD009270. DOI: 10.1002/14651858.CD009270.pub 2.

3)    Devinsky O, Marsh E, Friedman D, et al. Cannabidiol in patients with treatment resistant epilepsy: an open-label interventional trial. Lancet Neurol. 2016; 15(3): 270-278.

4)    Peng WF, Wang X, Hong Z et al. The anti-depression effect of Xylaria nigripes in patients with epilepsy. A multicenter randomized double-blind study. Seizure. 2015; 29: 26-33.

 

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.

Blog #57: Sleeping on Your Stomach Increases Risk of SUDEP

My website’s Blog # 13 of November 14, 2011 discussed Sudden Unexplained Death in Epilepsy (SUDEP). We still do not know how to prevent this phenomenon or why it occurs. SUDEP is reported in fewer than one in one thousand epilepsy patients and it tends to occur among patients whose tonic-clonic seizures are poorly controlled. SUDEP affects adults more than young children. The most beneficial medical advice to prevent SUDEP is to closely follow medical recommendations and treatment guidelines to control seizures.

SUDEP is diagnosed when an autopsy reveals no other known cause of death such as drug intoxication, heart attack, uncontrolled continuous seizures (status epilepticus) or other identifiable diseases/abnormalities. Common scenarios involve epilepsy patients who go to sleep and then are found dead in bed. Most of these cases are thought to occur after a seizure, although this cannot always be proven. It is believed that seizure activity affects the brain’s regulating centers for breathing and heartbeat which can result in pulmonary edema, a common finding at autopsy in these patients. Pulmonary edema is a congestion of the lungs that can be lethal by impairing breathing.

New information found a significant association between SUDEP and sleeping on one’s stomach, i.e., the prone position. ⁽¹⁾ The researchers conducted a literature review and documented 253 SUDEP cases. They found that 73% of the deaths occurred in individuals discovered dead and on their stomachs in bed. There was no evidence that a convulsion had occurred, i.e., no incontinence nor tongue/lip biting. Twenty-seven percent were found dead in other sleep positions. People younger than 40 were four times more likely to be found dead in bed on their stomachs than older individuals. It is not known why SUDEP is associated with this sleeping position nor why it is less likely to occur in people over 40 years of age.

I suggest patients sew a ball or similar object on the front of their bed clothes that would make sleeping on their stomachs very uncomfortable. This could be considered to further minimize this rare risk of death in epilepsy.

 

1.      Liebenthal JA, Wu S, et al. Association of prone position with sudden unexpected death in epilepsy. Neurology 2015;84:703-709.

 

 

 

 

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 as an eBook, an audiobook and a soft cover.

 

 

Blog #25: High Risk of Falling and Fractures in Epilepsy

(This blog was originally posted on July 25, 2012)

 

          A report in the July 10th 2012 issue of Neurology found that patients with epilepsy who take antiepileptic drugs (AEDs) are at increased risk of falls and bone fractures. Interestingly, their fractures were not necessarily related to falls due to a seizure episode. Advanced age was a risk, compounded by AED-associated dizziness and unsteady gaits. Fractures commonly involved spine, clavicle and ankles. Women on AEDs had a higher incidence of falls compared with nonusers of AEDs (1).

          Most epilepsy patients in the study were unaware of these increased risks.

          The AEDs with significant negative effect on bone health include phenytoin (Dilantin), primidone (Mysoline) and Phenobarbital. The data on valproate (Depakote) and carbamazepine (Tegretol) are not as clear. No definite data are yet available on the newer AEDs (2) (3). Bone density diminishes as duration on AEDs and the number of AEDs increases.

          In light of these findings, patients should continue to take prescribed AEDs, increase physical activity in safe environments and take Vitamin D and calcium supplements as recommended by their treating physicians.      

 

1. Ahmad BS, Hill, et al. Falls and fractures in patients chronically treated with antiepileptic drugs. Neurology 2012; 79: 145-151.

2. Gross RA, Gidal BE, et al. Antiseizure drugs and reduced bone density. Neurology 2004; 62: no 11 E24-E25.

3. Beerhorst K, Schouwenaars FM, et al. Epilepsy: fractures and the role of cumulative antiepileptic drug load. Acta Neurol Scand EPub 2011 Mar 21.

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. Conner’s Little “Dings” is his first novel.