Transcription:
Epilepsy Management

Melanie Cole (Host): Welcome. Today, we’re talking about epilepsy and the Epilepsy Center at University of Kentucky Healthcare. My guest is Dr. Ima Ebong. She’s a neurologist with UK Healthcare. Dr. Ebong, tell us a little bit. People have heard this term epilepsy for years. What is it and how would somebody know? What are the symptoms?

Ima Ebong, MD, MS (Guest): Okay, good morning Melanie and thank you for having me. But before I get into what epilepsy is and what are the symptoms; I first need to say what a seizure is and then that’s how our audience will understand next what epilepsy is.

So, first a seizure. A seizure is considered an uncontrolled electrical activity of the brain. So, I try to tell my patients to think of it as a short-circuit. A lot of people know about electrical signals from their devices, so think about the brain as short-circuiting. So, I tell my patients, you know they typically see what’s on TV, in the movies and when someone has a seizure; it’s abnormal movements.

But that’s not the only type of seizures that people can have. For instance they can have abnormal feeling, they can have abnormal sensations such as feeling like there’s a rising sensation in their stomach or feel abnormal taste in their mouth, like a metallic taste or even they may hear things and also a seizure can also cause loss of consciousness for a few minutes or so.

So, those are different types of seizures. And seizures can be provoked and by provoked that means something cased the seizure to happen at that moment for instance, alcohol withdrawal is common. So, you might see people who drink a lot of alcohol, a few days later if they stopped, they can have a seizure, or if they withdraw from certain types of drugs such as Xanax, like those types of drugs called benzodiazepine drugs. They may have a withdrawal seizure. So, those are provoked.

Epilepsy on the other hand, involves unprovoked seizures so not ones that are due to alcohol withdrawal or some type of drug withdrawal. And epilepsy by definition is having two or more unprovoked seizures greater than 24 hours apart. So, when I say unprovoked, I mean due to something structurally abnormal in the brain for instance, people who have had strokes; that’s a structural abnormality. Or they might have a bleed in the brain; that’s another type of structural abnormality. Or a tumor; that’s another type of structural abnormality in the brain. Or it doesn’t have to be a structural abnormality per se; it may be some type of genetic abnormality that the person is inherently born with that might cause their epilepsy.

And then another definition that’s newer than the two or more unprovoked seizures greater than 24 hours apart is if the patient has one seizure, one unprovoked seizure and then they are at higher risk of having a recurrent seizure. Then they will be diagnosed with epilepsy.

Host: Wow that’s a lot of great information Dr. Ebong and so well put. So, tell us, some people might have these seizures and pass them off or a parent might notice; are there potential consequences for patients if epilepsy goes untreated? How common is it for people not to seek treatment?

Dr. Ebong: So, there are consequences for epilepsy to go untreated. One of the biggest and most dangerous ones that I am concerned about is called sudden unexpected death in epilepsy or SUDEP and that, as the name implies death is the consequence of having uncontrolled seizures and typically these seizures are the generalized tonic-clonic seizures which are colloquially or commonly called grand mal seizures. And that has a high risk of having death in epilepsy. So, we always tell patients epilepsy is not benign; there is always a risk of death. And not just death, there are other risks as well too.

Seizures that are not properly controlled can lead to subsequent memory loss, or cognitive decline meaning that the person may not behave the way that they would normally do, have behavioral problems that could lead to depression, can lead to anxiety. Other things that are downstream effects of uncontrolled epilepsy is just damage to the brain, in and of itself.

So, we have to consider all of these things in terms of seizure control or control of epilepsy.

Host: When does it tend to show up? Is there a certain time? Does it only happen to children? Can adults get this as well?

Dr. Ebong: So, epilepsy, if you look at the data; there are two extremes. So, epilepsy typically occurs in the early years of life, so in newborns and infants and in childhood. And then you see another peak at the later stages of life and the reason why in the early years you see more of the genetic abnormalities that I was alluding to earlier. So, those types of epilepsies occur earlier in life. Later in life, again, on the other end of the spectrum; we have people who have strokes, we have persons who have tumors, and so at the end of the spectrum you also see a surge in epilepsy in the older population. So, we always tell patients that yes, epilepsy can come at any age, at any time. But the risks are higher at the extremes of the age groups.

So, we always tell our older patients that they are not out of the woods when it comes to seizures, that it is not just a childhood disease, that they can become affected as well.

Host: That’s really great information and thank you for clarifying that. So let’s you’ve mentioned the diagnostic criteria and you’ve explained it so well, so then what is the first line of treatment? Speak about medications that are available. What do you do with patients once you have determined that this is the situation for them?

Dr. Ebong: So, once I’ve determined that a person has epilepsy; there are many things that I have to weigh before I determine what is the right treatment plan for them. So, without getting too detailed, there are two classes of epilepsy. There are generalized epilepsies where the seizure happens or begins from the whole brain at the same time. So, the whole brain is involved. That’s the simplest way of putting it. And then we have focal epilepsy and as focal implies, the seizure starts off from one area of the brain and it can stay in that area or it can spread to the other parts of the brain.

So, certain drugs are better for focal epilepsies and others are better for a generalized. But then there are some that are good for both. We call them broad-spectrum antiepileptic drugs. So, that’s what I consider first, what would be the best drug for that type of epilepsy. Then I have to consider the patient’s other risk factors. For instance, there are some drugs epilepsy drugs that are very good for treating seizures, however, they can cause some unwanted side effects.

So, one common and one of the older drugs that we use that most patients may have heard of is called valproic acid and valproic acid is also know by it’s trade name Depakote. It’s very good at treating seizures and also is used in psychiatry for mood disorders, however, one of the biggest risk factors is that it can cause birth defects. So, in my patients who are women of childbearing age; I do not go straight to the drug because I know that there’s a risk of birth defects.

Other risks for that again in this population, is the risk of developing polycystic ovarian syndrome which is known as PCOS. And this is a disease where the woman can develop cysts in her ovaries, develop obesity, develop hair in her chin and neck or other parts of the body that’s unwanted and also can lead to infertility. So, again, I wouldn’t consider that in a woman of childbearing age.

Other side effects if Depakote that I would have to consider before I start in anyone, not just women is that it can cause some hair thinning or balding and it can also cause obesity in men and women. So, again, it’s a very good drug and its’ great for many of the generalized epilepsies and I do have some patients on it, but again, I have to think about those things. I have to weigh the risks and benefits before starting it.

Another type of drug that a lot of people know of because it’s a pretty common epilepsy drug, this is for both generalized and focal epilepsy is levetiracetam it’s also known a Keppra. Again, a very good drug and not as many side effects like I mentioned with the valproic acid or Depakote, however, I do have to consider patients who have depression and anxiety because this drug is known to worsen moods in certain patients and there are studies that have shown that it can also lead to suicidality.

So, again, if my patient is very depressed and anxious and I should preface this and say that on all of my epilepsy patients when they come to my clinic, they receive a screen for depression and anxiety because that helps me determine what medications might be the best for them. So, if I see that there is depression anxiety in those patients; I am hesitant to go ahead and prescribe the levetiracetam. So, those are just two examples and I can go through other medications but again, the reason why I say this is that I put a lot of thought into what treatment is best for the patient. I just don’t treat the seizures alone. I just don’t treat the epilepsy alone. I have to look at the patient as a whole person and ensure that I don’t cause any unwanted or adverse effects in my patients.

Host: Well that’s a perfect segue into my next question. Which is tell us about the benefits of seeking treatment at an Epilepsy Center like the University of Kentucky Healthcare and what can patients and their families expect when they are seen by you or one of your team members? Tell us a little bit about your multidisciplinary care.

Dr. Ebong: Yeah. So, when a patient comes to the University of Kentucky for treatment of their epilepsy; like you said, it’s multidisciplinary care. So, first they would see a neurologist or an epileptologist. An epileptologist is a neurologist who has had additional training in epilepsy. And in addition to seeing the epileptologist they may have an EEG to help us confirm the diagnosis and that EEG which stands for electroencephalogram is performed by one of our very well-trained technologists and they would do the EEG either in the inpatient setting or in the outpatient setting.

In addition to our technologists, we also have epilepsy nurses who correspond with the patients by phone, answer any questions that have to do with epilepsy education and also provide sort of a link between the physician and the patient. In addition to our nurses, we have also support staff, social workers, that can help arrange for anything that a patient and their family needs in regards to epilepsy whether it might be respite care for caregiver or if the patient has other comorbidities related to the epilepsy for instance if they cannot walk, have an intellectual delay; we can set them up with services. And we also closely link with the Epilepsy Foundation of Kentuckiana the Lexington Chapter.

And as a matter of fact, if you don’t mind, I do want to plug our Epilepsy Education Day which is coming up on June 8, 2019 here at University of Kentucky. It will be done in conjunction with the Epilepsy Foundation of Kentuckiana and the Epilepsy Education Day is open for all persons with epilepsy as well as their caregivers and family members. It will be a fun day with free lunch. The entire Education Day is free, and we will have physicians, epileptologists such as myself and colleagues as well as our nurses, our technologists there to answer any questions related to epilepsy. So, we are looking forward to having that fun day as a day for epilepsy awareness.

Host: As we wrap up Dr. Ebong, give us your best advice about epilepsy and one of the things I’d like you to just cover in this summary is what to do if you see someone having a seizure because that is something people do not know and it’s great information that can help someone right now. So, give us your best advice and tell us what is the standard that people should be doing? We used to hear about a lot of things. So, wrap it up for us and tell us more about epilepsy.

Dr. Ebong: Okay. So, if you see someone having a generalized seizure and again, you hear terms such as grand mal or tonic-clonic, but if you see them having that type of seizure; get them lying down into a safe place, on their back. It could be on the floor, but just somewhere where they won’t hurt themselves. Do not put anything into their mouth. So, I know that there might be tips that you might see online or elsewhere that say put something in their mouth, so they don’t bite their tongue. Do not do that. Don’t put anything in their mouth. You might risk breaking their teeth, just let the seizure happen.

Typically seizures usually self-resolve in less than five minutes, however, if the seizure is ongoing call 9-1-1 right away so that EMS can come and give any additional medications that are needed on the scene and then the patient can come to the hospital for more evaluation. If the seizure does resolve on it’s own; you can call your primary care doctor who can see you or refer you to an epileptologist for further evaluation of the seizures if no diagnosis is made.

And then the diagnosis can be made from there. Do not wait. I would tell anyone, don’t wait, just bring your loved one into the hospital or take them to see their primary doctor and like I said earlier, seizures come in all flavors. They are not always just abnormal movements. If you notice that your kid is staring off or not paying attention in class; don’t just blow it off and say oh, it might be ADD which is attention deficit disorder. Talk to your primary care doctor because that might be a type of seizure as well called an absence seizure. If you see your child having jerking movements in the morning just don’t think that it’s some type of strange behavior, that also can be a seizure. So, just always, just pay attention and talk to your doctor and then once the appropriate tests are performed and a diagnosis is made; please know that there are treatment options.

Host: That’s such important information. Dr. Ebong, thank you so much for joining us today and really educating us on epilepsy. And that wraps up another episode of UK HealthCast with University of Kentucky Healthcare. Head on over to our website at www.ukhealthcare.uky.edu for more information on the Epilepsy Center and to get connected with one of our providers. If you found this podcast informative, please share on your social media and be sure to check out all the other interesting podcasts in our library. I’m Melanie Cole.