Transcript special patient groups1

Special groups
Women
Women of child bearing age provide epilepsy
professionals with unique treatment dilemmas
•Epilepsy drugs and appearance
•Female hormones and seizure control
•Fertility
•Contraception
•Pregnancy
effects of drugs
effects of seizures
Carbamazepine
Sodium Valproate
Lacosamide
Leveitracetam
Zonisamide
Commonly
used AED’s
Clobazam
Lamotrigine
Pregabalin
Phenytoin
Topiramate
•Carbamazepine / Oxcarbazepine / Eslicarbazepine /
Topiramate / Phenytoin / Phenobarbitone / Primadone
all induce hepatic P-450
•These effect the metabolism of oestrogens and
progestogens
•Leading to ineffective Oral Combined Contraceptive Pill
(OCP) at normal doses
•These will also effect emergency contraception
•Lamotrigine levels are significantly reduced by the OCP
Recommendations…..
For women taking enzyme inducing medications:
Works Well
Caution
Not recommended
•Coil / Mirena
•Barrier
•OCP (increased
dose required)
•Depo (time)
•Emergency
contraception
•Implant
•Patch
•Progestogen
For women NOT taking enzyme inducing medications:
Works Well
•Coil / Mirena
•Barrier
•OCP
•Implant
•Patch
•Emergency
Contraception
Caution
•Depo (time)
•Progestogen
For women taking Lamotrigine
Works Well
Caution
•Coil / Mirena
•Barrier
•Implant
•Patch
•Emergency
Contaception
•OCP (recommend slight
increase in Lamotrigine
dose)
•Depo (time)
•Progestogen
Pre-conceptual counselling women with epilepsy
• All women with epilepsy
who are considering
becoming pregnant
should be offered
specialist advice and
information
All epilepsy medications will increase the risk of having a
child with a major congenital malformation
Background
2-3%
Sodium Valproate
5-9% **
Lamotrigine
3-5%
Carbamazepine
3-4%
For those on polytherapy the risks increase
CSM advice, Sept 2003
Women of childbearing
age should not be
started on sodium
valproate without
specialist neurological
advice
Pre-conceptual treatment choices
•Remain on current medication
•Change to alternative medication
•Withdraw medication (medication should NEVER
be stopped suddenly)
•Reduce medication for 1st trimester
•5mgs Folic Acid
Risk of passing epilepsy on…
Broad and imprecise
•1% if neither parent
•4% if father
•8% if mother
•25% if both parents
Essential Information…
•The majority have normal pregnancies
•Unchanged seizure frequencies throughout
•Will have to continue to take epilepsy medication
•Medication should not be stopped or changed during
pregnancy (unless under specialist supervision)
•Will have normal vaginal deliveries
•Should be advised to breastfeed
However…
•There is an increased risk of maternal death
•The effects of seizures on a foetus are unknown
•All pregnancies should be treated as high risk and
under consultant led care
The majority have normal pregnancies with normal babies
Post Natal Advice
• Child/mother safety:
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


feeding
sleep deprivation
bathing
carrying
safety outdoors
Catamenial Epilepsy
Direct link between seizures and menstrual cycle in about 12% of
women with epilepsy
Approximately 70% of women notice increase frequency of
seizures around menstruation
Clobazam 10mgs daily
Teenagers
Issues
→Compliance / denial
→Further education
→Driving
→Alcohol / recreational drugs
→Independence
→Employment
→Safety
The Elderly
Issues
→drug tolerance
→misdiagnosis
→co-morbidity
→Independence
→safety