When to Initiate Therapy in Patients With Epilepsy
With considerations for specific patient cases, the panel debates when the optimal time to initiate therapy for epilepsy would be.
Michael R. Sperling, MD; Kathryn A. Davis, MD, FAES; Trevor J. Resnick, MD; and Jesus E. Pina-Garza, MD
PUBLISHED February 25, 2019
Michael R. Sperling, MD: We’ve spoken about diagnostic markers and treatment, but one could back up a step and ask, when do we initiate therapy and make that decision to initiate therapy? I can lay out a few scenarios that might be a little challenging and might not provoke unanimous agreement from this panel. So, for example, if a woman comes to you who’s barely a woman, she’s 17, who had a single seizure and let’s say does not fit any obvious syndromic classification. So, she came with what we would suspect is a focal to bilateral tonic-clonic or a generalized tonic-clonic, we can’t know because she just stiffened and shook. And say she has an EEG [electroencephalogram] at the time of her initial office visit, which is normal, and the CT [computed tomography] scan at the emergency department was normal, although we’ll still get an MRI [magnetic resonance imaging]. Would you start her on therapy or not? Maybe I’ll start with Kate.
Kathryn A. Davis, MD, MS, FAES: In that instance, I would not start her on therapy if her examination was normal, EEG was normal, and there was no clear history of prior seizures. So that would be something I would clearly ask in depth about, whether there was any history of morning myoclonus, whether there was a history of auras or stereotype symptoms that could be concerning for unnoticed seizures previous to that event. And then I would obtain a brain MRI. If all of those pieces were unrevealing, I would not start seizure medication for that first seizure. I would counsel the patient that there was about a 30% chance of having a second seizure, and if there was a second seizure, we would likely start therapy.
Michael R. Sperling, MD: Trevor, you agree?
Trevor J. Resnick, MD: Yes, but I think what we’re doing is having a discussion of relative risk. And, obviously, when the scenario that you posited comes up, we look at all the different variables such as the 17year old who in the next few years may be pregnant. And the risk of a second seizure, depending upon what her occupation is. So all these issues come up for discussion and are relevant in terms of your decision making. I think certainly from the standpoint of normal imaging, normal exam, normal EEG in a first-time seizure, I think most people at that point would choose not to treat but to counsel very carefully about the various risks that are associated with not treating.
Michael R. Sperling, MD: Now, of course, her mother then points out to you that it’s March, she’s graduating from high school in 3 months and is planning to go away to college in a city as far as she can possibly be from her parents. So if she lives in Miami, she’ll go to Seattle. If she lives in Chicago, her choices are not quite as far, but she can still go a distance. And the mother says, “But she’s going to be far away.” Does that make a difference to you?
Jesus E. Pina-Garza, MD: I think this is a very challenging and unfortunately common scenario. So I feel that in most cases I completely agree with Kate, that those are the data, 30% chance of having a recurrence. The problem is when you’re the 30%, and the problem in this age is you have a little bit less cushion than we have in some of our pediatric cases.
Michael R. Sperling, MD: But she’s still pediatric.
Jesus E. Pina-Garza, MD: She’s still pediatric, but she entered the driving age.
Michael R. Sperling, MD: Yes.
Jesus E. Pina-Garza, MD: That’s the big difference.
Michael R. Sperling, MD: And the living away from home age.
Jesus E. Pina-Garza, MD: So having a seizure, unfortunately, in many cases, is a very traumatic experience and it can be a serious experience. But what makes it really a highly likely fatal experience is the circumstances where you have it. So driving, that’s an additional ingredient I often regard for my patients. I say, what if it was my kid or myself? And it would be completely, definitely up to that 17 year old to make the decision, but preventive medicine works always better than restoring medicine. So, if you have a seizure driving, you may have a serious injury or a fatality. If you prevent it, you may have a very long life.
Michael R. Sperling, MD: So are you saying you’re recommending a drug for her?
Jesus E. Pina-Garza, MD: I’d consider it for sure.
Michael R. Sperling, MD: What if he were a he rather than a she, would that impact your decision, Kate?
Kathryn A. Davis, MD, MS, FAES: No, it would not in this instance. I think in other instances, that gender difference does. So that’s more in a patient that has chronic epilepsy, a patient who’s had epilepsy maybe onset a few years earlier and is transitioning to my clinic and now preparing for college. That’s a very common scenario, and, in a young woman, at that first office visit after a transition, we’re starting to talk about preparing for when they do want to have a family and getting on a medication regimen if they need medicines that will have the best safety profile for pregnancy. I think college is a tough time, too. I often will counsel patients if they’re tolerating their medicines to wait until a break from college to make major changes, again, because they’re away from their parents. And, if they have a breakthrough seizure in college, it can mess up an entire semester or even lead to them dropping out of college, unfortunately.