Blog # 176: FOUR FIRST LINE ANTIEPILEPSY DRUG SIDE EFFECTS COMPARED

 

A multi-center study in Neurology Today September 19, 2024; volume 24; issue 18; page 9 entailed results of clinical investigations in 37 tertiary epilepsy centers in the United States, Australia and Europe. The goal was to advise clinicians and patients as to the most effective antiepilepsy (AED) drugs with the BEST TOLERATED SIDE-EFFECTS. Keppra, Lamictal, Tegretol and Trileptal are all available as generics and are widely used. More drug side effects may result in patients stopping their meds despite their effectiveness.

From 2012 to 2020 two hundred twenty-five adults were studied. Of the participants 132 were taking levetiracetam (Keppra), 55 taking lamotrigine (Lamictal), 19 carbamazepine (Tegretol) and 19 oxcarbazepine (Trileptal). There were no significant differences in total Adverse Event Profiles (AEP) screening for depression and anxiety among the 4 drugs. Those on Keppra were three times more likely to have feelings of AGGRESSION but almost half of these experienced feelings of UNSTEADINESS compared with Lamictal. Discontinuation rates were 42.1% each for Tegretol and for Trileptal, 34.8% for Keppra and 16.4% for Lamictal. Keppra had the highest discontinuation rate because of adverse events alone——18%—and Lamictal users had the lowest discontinuation rate—5%. Across medications female patients were more likely to report FATIGUE, DOUBLE VISION OR HEADACHE.

An anecdotal conversation occurred among 10 epileptologist neurologists. The question arose, “If you developed epilepsy what drug would you want to be on?” The unanimous answer was Lamictal. This study should lead to greater awareness of possible mental health consequences of using Keppra. Doctors should not be afraid to change drugs if Keppra users begin to feel anxious or depressed. This study is not yet generalizable for consideration to other forms of epilepsy or to epilepsy drugs not included in this study.

Epilepsy patients are more likely to have ANXIETY AND DEPRESSION. It is not known whether mental health treatment improves epilepsy seizure control. Psychiatric conditions are common in epilepsy patients even before epilepsy is diagnosed. Keppra can make patients FEEL EDGY, ANGRY or MEAN rather than they describing themselves feeling aggressive or in a “Keppra rage.” Spouses and family may notice these personality traits before the patients themselves do. Neurologists must be aware of these mental affects of these AEDs.

AED side effects can affect drug compliance and seizure control. One need not hold to the initial AED choice since other drugs may be more effective in seizure control with fewer emotional side effects. Keppra was found to be the most frequently prescribed drug as emergency room non-neurologists often choose Keppra when someone is admitted with their first seizure. Prompt AED change when indicated can be very positive in the overall life of an epilepsy patient.

 

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 #96: Neurologists May Be Missing the Higher Risk of Suicide/Drug Overdose in Epilepsy Patients

            A troubling picture is emerging: the deadly side of epilepsy. Epilepsy patients have a higher risk of unnatural death compared with the non-epilepsy population. SUDEP (Sudden Unexplained Death in Epilepsy) is not common, but suicide and drug overdose and other unnatural causes are.

            In the general population the actual risk of unnatural death is 0.3 to 0.5 percent of total deaths. People with epilepsy are five times more likely to die because of accidental poisoning from medication and three times more likely to die from an intentional overdose of medication compared to people who don’t have epilepsy. Although the researchers were already aware that people with epilepsy are at a higher risk of death, “…we didn’t know much about the risks of different types of death.”¹

            This population-based cohort study included more than 50 000 people with epilepsy and 1 million matched individuals without epilepsy who had identified in two data sets drawn from the general populations of England and Wales. Researchers reported people with epilepsy had a 3-fold increased risk of any unnatural mortality and a 5-fold increased risk of unintentional medication poisoning. Psychotropic and opioid drugs were most commonly used in poisoning, but not antiepileptic drugs. 

            Since people with epilepsy are at increased risk of unnatural death, they and their families should be advised about unintentional injury prevention and monitored for suicidal ideation, thoughts, and behaviors. The suitability and toxicity of concomitant medication should be considered when prescribing for comorbid conditions.

            Elizabeth Donner, MD,² director of the Comprehensive Epilepsy Program at the Hospital for Sick Children in Toronto, said, “Having good seizure control doesn’t mean the person with epilepsy is otherwise trouble-free or experiencing a good quality of life.” She added that death certificates may not list epilepsy as a contributing cause in suicide or drug overdose cases.

                Psychological counseling should be recommended for our patients who are at risk. A low threshold must be entertained for preventive education and intervention. Clinicians should query patients and their families about depression and addictive/and or dangerous behaviors to attempt to avoid tragedy.              

                

1.      Gorton CH, PhD; Webb RT, PhD; Carr MJ. PhD; et al. Risk of Unnatural Mortality in People With Epilepsy. JAMA Neurol. Published online April 9, 2018.

2.      Neurology Today. Volume 18/issue 10: May 17, 2018

 

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 #54: What Happens to Children with Epilepsy Later in Life?

 

            The complexities of living with epilepsy and questioning what the future holds are explored in the December 4, 2014 issue of Neurology Today. Jamie Talan, a journalist at the publication, reports a study presented by Dr. Anne T. Berg of Northwestern University at the American Epilepsy Society annual meeting in December, 2014. This same question—what does the future hold in epilepsy?―is juggled by the newly diagnosed third-grader Conner Golden and his family in my epilepsy novel, DINGS (ISBN 9781626463042).

            The experience of neurologists is that children who rapidly become free of seizures once an anti-convulsive medication regimen is begun usually remain seizure-free while they are on the medications. However, predictions of continued seizure cessation are less reliable once medications are stopped.

            The study reported by Dr. Berg included six hundred thirteen children aged from under one to fifteen years who had any form of epilepsy. It was carried out by researchers at Yale and Northwestern University beginning in 1993. Among the six hundred thirteen, five hundred sixteen of these children were followed at least 10 years; on average they were monitored for approximately seventeen years. A large percentage did well over the long term. About one-third of the six hundred thirteen was free of seizures within 2 years of the diagnosis and they were eventually able to stop their medications. Just one-quarter of that group which stopped medications were seizure-free for 5 years when the study ended. Twenty-five percent of the participants had seizure control, too, but only when they continued anti-convulsants. A further sixteen percent of the group continued to have seizures despite anti-convulsants but this group tended to have other neurological conditions complicating their epilepsy.

            Among the participants who were followed at least 10 years and who had been seizure-free for at least a one year period, fifty-two percent experienced a relapse. The researchers concluded that short-term remission of seizures did not guarantee long-term remission. Many reasons accounted for relapsing-remitting seizure control, including stopping anti-convulsant medications.

            Dr. Jacqueline A. French, a leader in epilepsy research, is quoted in the above Neurology Today article: “Neurologists have believed that they could stop medication if a patient was seizure-free for two years and that they would be fine for the rest of their lives […] but this is not the case. Two years may be too short [a time period] to determine whether a child will have problems with epilepsy again. We still don’t have a way to know which children will relapse.” Dr. Patrick Kwan, chair of neurology at the University of Melbourne and head of epilepsy at the Royal Melbourne Hospital in Australia commented on childhood epilepsy in the publication: “The data suggests that relapsing-remitting pattern of epilepsy control is not uncommon in children. This should be conveyed to patients when counseling them on prognosis. We need more studies […].”

            In conclusion, remission of seizures during the first two years of treatment is a favorable predictor of epilepsy-control but long-term future seizure-free life without anti-convulsants cannot be accurately foretold.

 

 

 

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 #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 #27: More Warnings About Dangers in the Shower

(This blog was originally posted on October 4, 2012)

                                
 

          I have previously written a blog (#7) on this website about the hazard of drowning in the bathroom shower. Several weeks ago I learned about another such tragedy. A young woman with epilepsy drowned in the shower. Apparently, she fell face-down and blocked the shower drain. This is an unrecognized danger among the physicians whom I teach, including neurology residents-in-training. At a recent conference I attended, the young neurologists were surprised when I discussed this with them. “I never really considered that,” was their typical response.

            If possible, people who have epilepsy should take baths and showers only when someone is home and the bathroom door is open. Nine patients cared for by my neurology group drowned at home. Three among these had a convulsion in the shower. They fell face-down and blocked the drain. Their faces were submersed under inches of water that collected in the basin. Mark Twain’s daughter, who had epilepsy, drowned in the bathtub. I remember one young woman I had treated for epilepsy. She was cautioned about the dangers of swimming alone in her backyard pool. One day her lifeless body was found floating by her pool maintenance workers.

            In addition, mothers who have epilepsy need to use care in holding their infants over bathtubs and hot surfaces. Dropping the baby during a seizure would be disastrous.

            One need not forsake these activities. Rather, the above scenarios are meant to remind people of these risks and that they should use appropriate precautions.

 

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

Blog #18: Uncontrollable, Medically-Resistant Epilepsy

(This blog was originally posted on January 24, 2012)

 

 

It is encouraging that approximately half of all of the people with epilepsy who participate in skilled treatment programs have excellent control of their epilepsy. However, one out of five persons with epilepsy still suffers seizures that do not respond to antiepileptic medications.

Neurologists diagnose “medically resistant” epilepsy when seizures interfere with patients’ quality of life despite taking adequate doses of two different antiepileptic drugs that are appropriate for their specific type of epilepsy. To be certain that the epilepsy is medically resistant neurologists must: correctly diagnose the condition; ensure that the proper choice of antiepileptic drugs was prescribed; and that the medication was actually taken by the patient.

Specialized neurological training is needed to differentiate between conditions that suggest seizures, but are not. These conditions include: psychogenic non-epileptic seizures due to emotional/psychiatric disturbances; syncope, or fainting spells that are occasionally associated with a few jerks of limbs/trunk; panic/anxiety episodes; and sudden sleep, as in narcolepsy. These conditions can be explored under the “Epilepsy Information” tag at LanceFogan.com.

 

 

 

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

 

 

Blog #14: Photosensitive Epilepsy

(This blog was originally posted on December 5, 2011)

 

          People can have seizures when exposed to certain stimuli. They are genetically predisposed to this phenomenon. There is a vivid scene in the recent movie release, Twilight Saga: Breaking Dawn, Part 1, in which bright lights in red, black, and white flash across the screen. Audience members in various cities across our country are reported to have suffered seizures while watching that scene. One man in Utah was said to be mumbling and blinking his eyes according to his wife. At least one person was taken by paramedics to an emergency room. In 2009 viewers suffered convulsions watching the movie Avatar. It is not known if any of these individuals ever had prior seizures.

Photosensitive epilepsy is a form of reflex epilepsy—seizures provoked by a specific stimulus, such as strobe or flickering lights. Some people find exposure to red-colored flickering lights, like the flashing red color in the Twilight film, induces seizures. Natural light—such as sunlight through leafy trees while driving, or waving a hand with spread fingers in front of a light source—can cause a seizure. Other examples include reading that induces certain eye movement patterns, or sound patterns heard in specific musical passages. Even anticipating, or thinking of eating food (this is rare), is known to cause reflex-type seizures.

Seizures while playing video games or watching TV is a recognized phenomenon. These events can consist of suspension of activity during which the mind is blank for several seconds to minutes followed by confusion or a genuine convulsion. Some people will jerk just one or more limbs, called myoclonic jerks. Electroencephalogram (EEG) laboratories routinely assess for this sensitivity to flickering lights. Patients are exposed to strobe lights during the EEG to test for abnormal paroxysmal patterns.

Those susceptible to reflex seizures should avoid exposure to that particular stimulus. If this fails to prevent seizures, then neurologists can prescribe anticonvulsant medications.

 

 

 

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

 

Blog #10: Is It a True Epileptic Seizure or a Faked, Psychogenic Seizure With a Psychological Cause?

(This blog was originally posted on September 23, 2011)

 

          Neurologists have long been aware of fake seizures. These are called pseudoseizures or psychogenic nonepileptic seizures. They can be involuntary due to psychological disturbances. They can also be voluntary-malingered faked seizures. These pseudoseizures occur in up to a third of patients evaluated in epilepsy clinics. One-third of patients who suffer from true epilepsy have additional pseudoseizures.

          Pseudo or false seizures are not originating from a brain abnormality that produces actual epileptic seizures. Diagnosing pseudoseizures can be very challenging. These feigned seizures can include self-injury with lip and tongue-biting and incontinence of urine and/or stool as we observe in true epileptic seizures. However, if an electroencephalogram (EEG) is attached to the person exhibiting gross seizure-type activity, e.g. jerks and vocalizations, the EEG will be normal, in contrast to a true epileptic seizure. The EEG is the most reliable way to make a correct diagnosis.

Patients exhibiting feigned, or pseudoseizures, tend to have significant emotional problems. Schizophrenia, hysteria and hypochondriasis are common diagnoses. Their psychogenic nonepileptic seizures tend to occur when other people are present and during times of heightened emotional stress when secondary gain is available. Whereas true epileptic seizures each tend to appear the same to an observer in any individual patient, i.e. they are stereotypical, psychogenic nonepileptic pseudoseizures manifest differently each time. Additionally, they can last many hours and end abruptly without any typical post-seizure confusion.

Recent studies confirm that psychogenic nonepileptic seizures are prevalent in US veterans. In the September 6, 2011 edition of Neurology, M. Salinsky, et al., reviewed patients who had been admitted to an epilepsy monitoring unit in Portland, Oregon’s Veterans Affairs Medical Center over a ten year interval. Their subjects included 203 veterans and an additional 726 civilians from an affiliated university. Twenty-five percent of the veterans and twenty-six percent of the civilians experienced psychogenic nonepileptic seizures. The correct diagnosis of psychogenic nonepileptic seizures was delayed an average of five years in the veterans versus one year in the civilians. The attending doctors probably did not challenge the epilepsy diagnosis because post-traumatic stress and mild brain injuries—definite conditions associated with epilepsy—are common among battlefield veterans.

  Veterans with psychogenic nonepileptic seizures tend to have higher rates of anxiety, post-traumatic stress disorder and chronic pain, as compared with veterans with true epileptic seizures. Civilians with psychogenic nonepileptic seizures usually attribute their seizures to a past head injury, usually mild ones.

 Psychiatric care can be helpful in treating psychogenic seizures, but success in minimizing or deleting them and stopping the anticonvulsive medications is not always achieved.

 

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