Blog #177: Heart Attacks, Strokes and Cardiovascular Dangers from Some Epilepsy Drugs

 

 

If your seizure control is not satisfactory, and if you and your doctor are trying different antiepileptic drugs (AED), be aware that some side-effects can be more common with certain AEDs and less with others. Your choice could be beneficial for you. This topic was reviewed by Mary Beth Nierengarten in the November 21, 2024, issue of Neurology Today page 9. Older adults with epilepsy are much more likely to experience new cardiovascular events, including strokes, transient ischemic events (TIA) and heart attacks if they take the enzyme-inducing antiepileptic drugs.¹

Enzyme-inducing antiepileptic drugs (EIAEDs) are a class of medications used to manage seizures. They have the effect of increasing the activity of certain liver enzymes, primarily the cytochrome P450 (CYP450) family. How Enzyme Induction Works:

•    EIAEDs, the enzyme-inducing drugs, stimulate the production of CYP450 enzymes in the liver.

•    These enzymes are responsible for metabolizing (breaking down) many drugs and other substances in the body. Carbamazepine (Tegretol), Phenytoin (Dilantin), Phenobarbital (Luminal)and Primidone (Mysoline) are the classical enzyme-inducing antiseizure drugs (ASDs). Non-enzyme-inducing ASDs include Levetiracetam (Keppra), Lamotrigine (Lamictal), Lacosamide (Vimpat). The EIAEDs were used in a third of those with the increased risk and this Canadian study (reference 1) highlights the risk of long-term use of these medications for epilepsy. Co-morbidities with other medical diseases, especially cardiovascular risks, should be considered when choosing among 25 commonly used AEDs.

Those patients studied ranged in age from 62 to 85. Most were white. males and females of comparable numbers. None in the study had had a previous reported stroke, transient ischemic attack (TIA) or heart attack but the study showed 24.6% of the enzyme-inducing ASMs were then associated with new-onset cardiovascular events. Consider these findings, if possible, with your doctor when choosing your first-line therapy, avoiding Tegretol, Dilantin, Phenobarbital, and Primidone. If you have cardiovascular symptoms and risks, consider an EIAED as Levetiracetam (Keppra), Lamotrigine (Lamictal) or Lacosamide (Vimpat). Other common AED adverse effects, e.g. balance and cognition problems, should also be discussed with your physician.

We need to take a comprehensive approach for long-term outcomes for patients with epilepsy as most patients with epilepsy will be on these medications for decades or life-long.

 

1.    Li J, Shlobin NA, Thijs RD, et al. Antiseizure medications and cardiovascular events in older people with epilepsy. JAMA Neurol 2024; Epub 2024 Sept 30.

 

Lance Fogan, M.D., is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. His hard-hitting emotional family medical drama, “DINGS, is told from a mother’s point of view. “DINGS” is his first novel. Aside from acclamation on internet bookstore sites, U.S. Report of Books, and the Hollywood Book Review, DINGS has been advertised in recent New York Times Book Reviews, the Los Angeles Times Calendar section and Publishers Weekly. DINGS teaches epilepsy and is now available in eBook, audiobook, soft and hard cover editions.

  and is now available in eBook, audiobook, soft and hard cover editions.

Blog # 156: Fatigue and Epilepsy

 

BJ Mac, Medical and Health Writer, and neurologist,  Amit M. Shelat, D.O., reviewed this subject in 2021 and their observations will help explain common symptoms with your epilepsy.¹

Added to your epilepsy, you feel exhausted, tired, or weak. Fatigue is a much more common symptom in people living with epilepsy than in the general population. Feelings of exhaustion and weakness can affect daily quality of life. Understanding this, there are some ways to help manage epilepsy-related fatigue.

What Does Fatigue with Epilepsy Feel Like?

The fatigue felt by people living with epilepsy is characterized by mental and physical experiences of persistent and extreme weakness, tiredness, and exhaustion.

One patient described being more emotional because of fatigue: “Does anyone feel so tired that they feel sad? This often happens to me. I am on a lot of medication, and my seizures are not under control, so I guess I have many reasons to be tired.”

Another patient reported that fatigue causes daytime sleepiness: One patient described the impact of seizure-related fatigue on her quality of life, writing, “For several years, I wake up after a seizure, and I am tired for up to seven days and in bed pretty much all day every day. That is the primary reason I lost my job.”

What Causes Fatigue in Epilepsy?

Several factors can cause a person with epilepsy to experience fatigue.

Depression

Depression is a known comorbidity (co-occurring condition) of epilepsy, with symptoms that vary from person to person. A study² using measures called the Fatigue Severity Scale and Fatigue Impact Scale revealed a high prevalence of depression-related fatigue among people living with epilepsy.

This fatigue may sometimes trigger epileptic seizures. A cycle can start to develop: Depression causes fatigue, which contributes to seizures. These seizures then cause more fatigue, which contributes to depression, and so on. Talk to your doctor about how to treat depression to break this cycle.

Many patients agree that dealing with depression is a common aspect of living with epilepsy: “I never thought I would ever have to deal with depression. With epilepsy, depression is a daily battle.”

Nocturnal Seizures

Another important risk factor of developing fatigue when living with epilepsy is poor sleep or sleep impairment. Nocturnal seizures (seizures that occur while a person is sleeping) can affect a person’s sleep quality.

A person is considered to have nocturnal seizures if more than 90 percent of their seizures occur when sleeping, which is the case in up to 45 percent of people living with epilepsy.

Both generalized and focal seizure types can occur as nocturnal seizures. Nocturnal seizures tend to occur during the first, lighter stages of sleep or upon waking.

One patient described nighttime seizures as a source of fatigue: “I recently had several nocturnal seizures, and I am now very exhausted. It will take three days for my body to get back to normal. It takes so much out of you.”

Another person described how nocturnal seizures interrupt her sleep rhythm and cause fatigue the next day: “Does anyone else ever have a seizure in their sleep and find it hard to fall back asleep? Then during the day, it can completely take your energy away.”

Postictal Fatigue

There are several stages to a seizure:

• Prodromal phase — When symptoms begin.
• Aural phase — When altered perception or sensations occur.
• Ictal phase — The actual seizure.
• Postictal phase — Recovery time after a seizure.
• Interictal phase — The time in between seizures.

Postictal phases have been found to have higher chronic fatigue scores and fatigue impact scores than ictal phases, with people reporting more fatigue and lower energy during the postictal phase. In other words, the recovery period after a seizure is a time of intense fatigue.

Many people reported needing to sleep due to intense fatigue during this phase. “I always go to sleep after a seizure,” wrote one patient. “It’s often compared to running a marathon. Your muscles are weak, everything hurts, and you are plain tired.”

Antiseizure Medications

Antiepileptic drugs commonly cause fatigue. A change of medication or time to adjust to your treatment plan may be needed to reduce this fatigue.

One patient said about medication-related fatigue: “When I took that medication, I experienced fatigue, anxiety, fear, anger, and mood swings.” Offering some great advice: “When side effects become unmanageable, it’s time to talk to your neurologist and ask for a drug that has fewer side effects.”

Managing Epilepsy-Related Fatigue

Managing fatigue with epilepsy can be challenging because its different causes can be interrelated. Tracking symptoms of fatigue and discussing causes and treatments with your health care team is the best place to start.

1)     BJ Mac, Medical and Health Writer, Medically reviewed by
Amit M. Shelat, D.O. 2021

2)     Fatigue in epilepsy: A systematic review and meta-analysis Oh-Young Kwona , Hyeong Sik Ahnb , Hyun Jung Kimb, * a Department of Neurology and Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Republic of Korea b Institute for Evidence-Based Medicine, Korea University College of Medicine, Seoul, Republic of Korea

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. His hard-hitting emotional family medical drama, “DINGS, is told from a mother’s point of view. “DINGS” is his first novel. Aside from acclamation on internet bookstore sites, U.S. Report of Books, and the Hollywood Book Review, DINGS has been advertised in recent New York Times Book Reviews, the Los Angeles Times Calendar section and Publishers Weekly. DINGS teaches epilepsy and is now available in eBook, audiobook, soft and hard cover editions.

 

 

Blog #97: A REMINDER: SLEEP LOSS AND EPILEPSY

Epileptic seizures and sleep cycles is a complex realm of neuroscience that will not be addressed here. 

Epileptic seizures are often precipitated by a combination of various clinical factors, but, we find that sleep loss stands out as an independent seizure-trigger in neurology clinics. This variable can be controlled by our epilepsy patients. 

Below is a representative study. It supports obtaining adequate sleep of eight hours per night. In a prospective, observational cross-over study, 179 consecutive hospital admissions for epileptic seizures were included.¹ The sleep duration prior to the seizure, as well as alcohol, caffeine and drug use, were recorded.

Complete data for analysis were retrieved in 144 patients. The sleep-time during the 24 hours prior to the seizure was lower (7.3 hours) compared to follow-up (8.3 hours) longer seizure-free periods. Caffeine consumption and use of relevant non-antiepileptic drugs (AED) were not different.

I emphasize that sleep-rest is critical in helping control epilepsy. Be sure to get an adequate night’s sleep, preferably at least eight hours to support your anti-convulsant medications.

1)      Samsonsen C, Sand T, Bråthen G, et.al. The impact of sleep loss on the facilitation of seizures: A prospective case-crossover study. Epilepsy Research November 2016, Volume 127, Pages 260-266.

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 #50: Epilepsy Management

(This blog was originally posted on September 25, 2014)

 

 

 

 

There are four primary types of epilepsy treatment of which patients and their families need to be aware. 1) Medications. 2) Devices that stimulate the nervous system. 3) Special diets and 4) Brain surgery. These treatments need to be considered since approximately one out of every three patients with epilepsy does not respond adequately to anti-convulsant medications.

Surgery that removes the offending brain area from which seizures originate can possibly cure epilepsy. The other treatments are not curative. Neurostimulators generally reduce, but do not eliminate, the number of seizures. Such stimulators include: vagus nerve stimulators (VNS) that have a small battery-powered stimulator implanted beneath the skin in the upper chest with its stimulating wires winding up to contact the vagus nerve in the neck. Other battery-operated neurostimulators currently approved for use in the United States are surgically placed in the skull bone with its stimulating wires contacting the brain cortex. It responds if the device detects the onset of seizure activity. It “short circuits” the seizure and minimizes or prevents that seizure. Diets that favorably affect epilepsy are very specialized and for the most part aid young children whose epilepsy is uncontrolled. These diets are extremely restrictive regarding the foods that can be eaten.

I urge patients and their families to consider this information and to discuss with their neurologists if any modality is appropriate for their treatment.

 

 

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.

Blog #34: The Petit Mal (Absence) Seizure

(This blog was originally posted on June 1, 2013)

 

Is some young person a daydreamer, staring or blinking and not paying attention? Could it be a petit mal seizure? Sure, everyone can do these things. Everyone “tunes out” the outside world occasionally, but not excessively, and not to the point where they will not respond to you.

Petit mal seizures last only seconds and can happen many times each day. If you are suspicious that it is not just daydreaming, try this at-home-diagnostic-procedure for petit mal epilepsy. I have done this many times in my office with positive diagnostic results. Have the person sit and breathe hard, deeply and fast (hyperventilate) for up to two minutes. Expect this to cause some mild, light-headed, dizzy feeling. If petit mal epilepsy is the problem, probably, but not always, the person will suddenly stop the hyperventilation, stare or blink, and not respond to you. After 10-15 seconds, the person will get right back to hyperventilating and be unaware that he had just interrupted it. He will not know that he had just induced a petit mal seizure. Your physician will document what you found with an EEG (electroencephalogram or brain wave test) and start effective medications that will most likely stop the seizures from occurring.

 

The “petit mal” or “absence” seizure occurs in fewer than 8% of epilepsy patients. They are specific to children, the majority of which are girls. It is believed that petit mal seizures originate deep within the central areas of the brain. A genetic, inherited mechanism seems common. This type of epilepsy usually begins after age three years and usually disappears spontaneously in the late teens. Petit mal seizures can occur up to 50-100 times per day. During the seizure, the child stops talking or walking, without falling, for seconds and then resumes the activity as though nothing had happened. Friends and unsophisticated observers may consider the patient as “ditzy” and strange without realizing the presence of any medical impairment. People can suffer petit mal seizures for years before a correct diagnosis of epilepsy. Some patients assume that their inexplicable spells happen in everyone since they are so common in their own daily life. If the petit mal seizures do not cease by the late teen years, they usually transform into grand mal convulsions with tongue biting, incontinence and loss of consciousness. Unlike the tonic-clonic seizure that I described in Blog #33, there is no loss of body tone or convulsion during a petit mal seizure. There is no warning (aura) that the seizure will occur.

A petit mal seizure lasts between 10 and 15 seconds, during which time the individual appears to be “spacing out” with a motionless stare. There often is upward rolling of the eyes, or drooping of eyelids or mild twitching of eyelids and blinking. When the seizure is over, the person is immediately alert and aware of the environment/surroundings. The person will act as if nothing happened and be totally unaware that he or she had blanked out. If no one witnessed the event to tell the person about the seizure, i.e. the loss of contact with the environment, the patient may only realize that something happened after “missing” what someone had said during a conversation or the dialogue in a television program or movie in which he was particularly interested. Unlike a daydream, where the person is aware that his mind was focused on something, the petit mal patient’s mind is completely blank.       

Petit mal seizures can be precipitated by breathing fast and hard (hyperventilation) and by flashing lights. This light effect is produced naturally when moving through an area where sunlight shines intermittently through tree branches or from videogames or strobe lights. Therefore, the neurologist tests a patient for petit mal seizures with specific techniques during an EEG test. These include the person hyperventilating for a short period. The EEG test also includes a flashing strobe light while the patient lies under the lamp with closed eyes. Peculiarly, petit mal epilepsy can be especially sensitive to certain frequencies of the flashing lights. During the test, the light flashes go off at incremental speeds starting slowly and then up to 40 flashes per seconds. The classic petit mal EEG abnormality is called the “three spike-wave complexes per second” that occur throughout the brain.  Stress (both physical and emotional) can also elicit a seizure for people with epilepsy.

There is no immediate first-aid treatment for a petit mal seizure. The person will return to a fully alert and aware state within 15 seconds. You want to help the person get out of the path of oncoming traffic if the seizure occurred while he or she is crossing the street and prohibit driving until there is full control.

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. DINGS is his first novel.