Case-Based Insights: Expert Perspectives on the Treatment of Epilepsy - Episode 6
A key opinion leader discusses how to determine efficacy in the treatment for patients with epilepsy and concludes the discussion by providing advice for community neurologists.
Amit Verma, MD: The main way we determine efficacy is by the patient report or by family or caregiver reports. If we see somebody in the clinic, and the patient and the caregivers tell us they haven’t had a seizure, then that’s how we determine efficacy. There are going to be many times when the patient is unaware whether they’re having seizures if they don’t have an aura prior to their seizure or if they don’t have any injuries with the seizure. They also might not know whether they’ve had a seizure. There are going to be many times when the caregivers are unavailable. They’re not with the patient 24-7, so there are going to be times when the caregivers are not around, especially during daytime working hours where they might be at work.
Having said that, the benchmark that is still used most commonly is patient and caregiver reports. There are devices that can be used, such as the Embrace2 watch. If somebody has a generalized tonic-clonic seizure, it is going to send a message to whoever is programmed to receive that message that the patient had a seizure. There are some advances in technology that allow us to pick up seizures that otherwise would never have been picked up, but the benchmark for the moment is still patient and caregiver reports.
The main issue with community neurologists would be that, if somebody is still having seizures, they should try to be more aggressive in terms of trying to get the seizures under control. Many neurologists oftentimes think that, if a patient is having a seizure every so often, that would be considered good seizure control. Our goal should be seizure freedom always. Especially with the different medications we have available and the new mechanisms that are being targeted with some of the newer medications, we want to keep seizure freedom as the goal and do whatever we can to achieve that goal. Anything short of that is going to impact the patient’s quality of life by putting them at risk for injury or putting them at risk for sudden and unexpected epilepsy. They should just try to be as aggressive as possible about trying to reach that goal of seizure freedom.
The other advice I would give them is that they shouldn’t be scared about using some of the newer medications because there are a lot of resources available not only from the pharmaceutical companies but also from different meetings and from different societies, where a lot of data get presented about the new medications. It’s important for them to update themselves continually so that they are able to prescribe newer medications as they become available.
As far as referring a patient to an epilepsy center is concerned, if there comes a time when they’ve tried 1, 2, or 3 different medications, and the patient is still having seizures, at that point it’s proper to refer the patient to an epilepsy center to see if they could be candidates for epilepsy surgery or for other investigational treatments or device treatments. A lot of the medication treatments can still be accomplished, at least in the beginning stages, by community neurologists, but if the seizures become difficult to control, then it would be proper to refer that patient to an epilepsy center.
Referring back to the case presentation, this is a fairly common type of patient that we would see in our practices: a person who is cognitively normal who started to have seizures later in life, and the main issue for this patient is that we’re trying to get her back to work and be seizure-free. If we circle back to the goal of seizure freedom and what would make a medication a good choice for this particular patient, we would try to pick something that has once-a-day dosing, is well tolerated, and can be used at lower doses. Even though perampanel is a medication that has been around for 5 or 6 years, it’s still a good choice for patients like this because of its broad range of efficacy both for focal seizures and generalized onset seizures, and it can be used at lower doses with good efficacy.