how we learn in management.pdf · 2009-02-12 · dilantin (100) 1x3 phenobarb gr i 2x2 depakine...
TRANSCRIPT
1
Pitfalls in Management of Epilepsy ��.��.�������� �� !���"#
�#$#%�&#'�(�#�%��!# )#*%�&#+#!,��#�-�.
�/,"��0�1#%�2�!3�*/�&�� 3�4�!#5#/�� �*�����.
*6(7��!�#�-�. �8#%��!#/�!$+�7�"�
E-mail address: [email protected]
http://epilepsy.kku.ac.th
How we learn ?
• 10% of what we read
• 30% of what we see/heard
• 50% of what we do
• 70% of what we do,see and read
Pitfalls Clinical System
• �#�%���2C�! • *%#��DE, ����*-�
• �#�-�%2�#48E+4'G�5�-��#� • �#�H8E5���#�
• �#�H&E!#���&�� • *%#���IJ#���+�#�K�E��5!#• )#%(/�&��%��L-� (SE)
�#�%���2C�! : 'PQ8#
�'�(%�-�
�RDE�8S��8-,�#�6.
��%/#� IH&E��5RDE'T%!/�#! (21 min/1-5 min)
1/3 ���������� ������������� ������������������
2
�#�%���2C�!: 7�%�#4
�H8E*%#���H2��5�#!/(�+ !�$+4'�(%�-�
�5���0� VDO
�[��'�(%�-��#43������.
��D VDO �#�&��&���-"#4, +\I�]
Tics Truncal myoclonus
HOME VDO
E#K�"��I�H2 +!"#���I4%���2C�!%"#�'_�3�*/�&��
3
-�%+!"#4RDE'T%!
�8Q�4+#!, 28 'a +#& ��!#5#/
�� +#�#���(-,�$+4$#�(8%"#4�+�8/�5
�EEG �4��!%"#2(�'_� epileptic activity
�CT-brain: '�-�
���5!# sodium valproate: � $0g�
-�%+!"#4RDE'T%!
�3 ��\+�-"+�# ���������
���4%/��\I+4 teratogenic effect
�2(�J#+!"#4K�� ?
Teratogenic effect Teratogenic effect
4
Restless leg syndrome
�#�-�%2�#48E+4'G�5�-��#�
�EEG
�Imaging: CT, MRI-brain
�Blood chemistry : metabolic causes
�Therapeutic drug monitoring
������� ! ��""#����� : �%&'�
�K�"� 3�4�!#5#/�"4-�%2
�K�"� RDE7'�R/
�*%#�K%7/(*%#�2J#��#($+4�#�-�%2
�K�"� 45'�(�#6
�#�-�%2*/\I�Kmmn#��+4 : 7�%�#47�EK$
�K�"�"4-�%2�,��#!
��"4-�%2�C�#(�#!
�K�"��I�H2H��#�%���2C�!
����1#7/E%K�"-+5��+4��"4 EEG '�0�1#RDE�& I!%&#Q
�#�-�%2*/\I�Kmmn#��+4�*%#�K% 25-59%
�*%#�2J#��#( 78-98%
�R/5%�'/+� 2-41%
�-�%2 EEG )#!H� 24 hr *%#�K% 51%
�-�%2 EEG 8/�42#� 24 hr *%#�K% 34%
�#�-�%2 CT-brain
�$E+5"4& g
�K�"� 45'�(�#6
�30 5#� &"%!*�K�!8"#4K�/ 3�*() �)
5
$E+5"4& g�#��"4-�%2 CT-brain
�&��*��g47��+#!,�#��%"# 25 'a(������������)
�-�%2�5*%#�R��'�-��#4�(55'�(�#�
��#�&���C�#(� IK�"K�E����2#��gJ#-#/�D4
�+#�#�&���,�7�4$0g�, �D'755�'/ I!�K'
$E+5"4& g�#��"4-�%2 MRI-brain
��#�&��&��� CPS � IK�"-+5��+4-"+�#����1#
��#�&���,�&���� I���1#!#�2��4]
�� refer +����,-� -�&����������
�#�-�%2�/\+���I%K'
�CBC, BUN, Cr, electrolyte, Ca, Mg, PO4, LFT
��/\+��"4�'_�5#4�#!
�98% '�-�
�����������.���
������� 80 %
�+�����������,+�� 2%
���+����/�,�0�1�� 2��
�Liver, renal disease
�#�-�%2�/\+���I%K'
�#�-�%2%���(��5!#���&�� : 'PQ8#
�K�"� �#�-�%2%��3�!��I%K'
�7'�R/K�" D�-E+4
�Therapeutic level ???
�#�-�%2%���(��5!#���&�� : 7�%�#47�EK$
�'�(�#�4#�
���E#4�(55�"4-"+
��#�7'�R/� E#K�"&��K�"-E+4��4%/�(��5!#
� E#&�� H8E�D� I upper limit
6
$E+5"4& g�#��"4-�%2
��4��!����)#%(�'_���1$+4!#
���5'�(�#�!#���&��8/#!-�%7/E%*%5*,�K�EK�"�
�-E+4�#�-�%2*%#���IJ#���+$+4�#���5'�(�#�!#
�RDE'T%!� 3�*8�\+)#%(� I� R/-"+�(��5!# pregnancy,liver,renal disease
�#�H&E!#���&�� : 'PQ8#
��#����I�H8E!#���&�� H8E��S% $E+5"4& gK�"7�"&��
�$#��#�'�(����R/
�'G�����!#�(8%"#4!#���&��7/(!#+\I�]
��#�-�%2%���(��5!#���&��K�"K�E�J#
�#����I�H8E!#���&�� : 7�%�#47�EK$
��#�%���2C�! ��I�H2 100%
�-E+4� �#�'�(����R/�#�*%5*,��#�&��
�-E+4� �#�'�(����*%#���IJ#���+
�+#2-E+4�"4-�%2%���(��5!#���&��
���E#4*%#�������x.+��� �(8%"#47��!./RDE'T%!
RM
Seizure
AEDs
)#%(/�&��%��L-� : 'PQ8#
�K�"%���2C�!
�%���2C�!&E#
�H8E�#����1#K�" D�-E+4
Srinagarind Med J 1997;12:64Srinagarind Med J 1997;12:64Srinagarind Med J 1997;12:64Srinagarind Med J 1997;12:64----8888
7
�#����1#� D�-E+4-#�7�%�#4'G�5�-� 7 �#! (28%)
�K�" D�-E+4-#�7�%�#4'G�5�-� 18 �#! (72%)
��#�8-,�#����1#K�" D�-E+4
�7��!.K�"*�� 04 SE
�2J#$�#�!#K�"K�E
)#%(/�&��%��L-�: 7�%�#47�EK$
��#�&��� I�#��#��%"# 5 �#� H8E�4��!%"#2(�'_� SE
�H8E�#����1#-#�7�%�#4�#����1#
��yn#�(%�4+!"#4H�/E&��-"+��\I+4
��(%�4)#%( subtle GTC
Subtle GTC
System : 'PQ8#
�*%#��DE-"+3�*/�&��
�*%#��$E#H27/(����*-�-"+RDE'T%!3�*/�&��
��#�5��8#�2���#��(55�#�H&E!#
��#�5��8#�2���#� OPD
8
Limited Resources @ Awareness; family, doctor, teacher
@ Attitude; teacher, family, social
@ Appropriate health providerL doctor
L budget
L system
Knowledge in Epilepsy: Khon Kaen
@ What is seizure? 38.5 78.4 94.5
@ Alcoholic withdrawal 12.8 34.3 5.5
@ Genetic disorder 66.7 74.5 53.4
@ 2 years AEDs 33.3 56.9 47.9
@ Stop driving 89.7 79.4 79.5
@ Put something into mouth 80 64 50
@ Total score(50) 16.4 24.5 25.6
Family Teacher Medical Student
������������ ( ��!"� #�)1. f-�, � 1-5 ����2. ������)� GP3. �����+��� ,�+�2���4. ,�!����h�'����������� MRI5. ���� ����� ������f-�����1+�j6. ������k'��'�������l
!�%�&'%()&*+ ,-./0�1�*2��3�4#-
1. ���,�0�)�� �-�� ��������,'�.
2. ����������������-�����,�! �� '�������
3. l����������m�2����� ������+��nj���'�������
4. �������������! �,��� ���,�0���
Compliance with Treatment of Adult Epileptics in a RuralDistrict of Thailand. J Med Assoc Thai 2003;86:46-51.
�Patient-compliance (100%) over 1-year was 56.9%
�Misunderstanding of need long-term treatment 48.4%
�Forgetfulness 16.1%
�Economic problem 12.8%
�Misbelieve 6.5%
�No caregiver to escort them to hospital 6.5%
Anti-epileptic Drugs Available
Type of hospital PB PHT CBZ VPA New AEDs
Regional (%) 100 100 100 100 52.6
General (%) 97.9 97.9 97.9 94.7 16.3
District (%) 100 100 80 20 0
Community (%) 98.7 97.6 67.4 8.2 0.3
PB = phenobarbital, PHT = phenytoin, CBZ =carbamaepine, VPA = valproic acid, New Drugs such as Topiramate, Lamotrigine, Gabapentrin, Vigabatrin
9
-��������@ ����� GTC, CPS ���������l
@ ������2,�w���x'��'�������l
@ Epilepsy clinic 200 ��
@ 75 % ����l
@ 25 % ,����.����,'�.
@ 80 % ������1+�j, ����y�f������
System : 7�%�#47�EK$
��"4�����*%#��DE� I D�-E+4-"+'�(&#&�, *�D, 8�"%!4#�
��"4�����*%#��$E#H27/(����*-�� I� -"+'�(&#&�, *�D, 8�"%!4#�
�'��5'�,4�(55�#����1#2���#�3�!!0�RDE'T%!�'_��D�!.�/#4
����I�5�5#�$+4�!#5#/ �)��&��
��'/ I!�%�x *��H8�" ?????
� Clinical practice guideline : practical ? Yes or No
� �+. ���f'&���������l�y���� CPG ���
����2���� -�f'� �+. �����l�y����
Easy Epilepsy Clinic
Pitfalls of CPG
10
11
THANK YOU FOR YOUR INTEREST
CASE DISCUSSION
��/�w����
�����'&����. 22 �z )�� �-�� 10 �z
���������� y�,���
1��������� 6 ,�!��
��,����,����� 1 ��
���+� nystagmus
��2���,+� �,���
1 ,�!�� �2, �2�����������������������1 �����'j �������-��' ����h��.����h��� -�� ����f'�� dilantin ���h� 2 3 ,�m��������-������������� 2 4 ���h��� 2 ��������h�'�� 24 ,�m�f� 2 ������,�m��.��y�,���
12
Case Study
RDE'T%!&#!+#!, 45 'a ��52E#4
CC: &��5"+!�#�$0g� 1 ��\+�
PI : Case CPS � +#�#��E+4K8E +#/(%#� 8/�42#�� +#�#�&�� 5#4*��g4'a���#8+��(2#!$"#%$+48�D"5E#� H�&"%4 1 ��\+� � +#�#��#�$0g�
- Q#-��J#RDE'T%!�"43�4�!#5#/2�-�%&7/E% 7��!.�"4-�%�#��5�#����1#-"+
Problem
1. Intractable seizure
2. Psychotic symptom
Patient with chronic and
active epilepsy
1. Review diagnosis and etiology
� history
� EEG
� neuroimaging
� other investigation
2. Classify epilepsy
3. Review compliance
History
1. Q#-�H8ERDE'T%!8!,��#�!#���&��
2. ���1#�#4K�!�#�-�.
Psychotic symptom and epilepsy
��/�w����
�����-���. 25 �z ��-�+�������GTC 1 �z
Dilantin (100) 1x3
Phenobarb gr I 2x2Depakine (200) 2x3���.������������
13
�%&'�
1. ���.������������
2. �y��������������-��l�� 3 ��
1����������
1. ����2�������-��
2. ��2,��� compliance
3. � local '�!� original
� �����2,���
1. �2�������-��� y�'���.�-���
2. Poor compliance
3. � local
��������f'��
1. ����,�0� monotherapy, original
2. Dilantin (100) 3 ,�m��������
H3#--��I40*�-#�4#-1. Monotherapy
2. Low initial dose
3. Individualized
4. Brand name
5. Assessment
��/�w����
�����-�����. 38 �z
������,�0�)�� �-���� 8 �z
����������� y�,��� 1�����.�������
14
��2���,+� �,���
������������� 1 2,�������
���� amitriptyline ��� ��
1�'���������{���1 2 ����� ��
)����,�����y�f'� ��������� febrile convulsion
�LMH�
1. N�O�����N0�I�
2. �LMH���, ��#�
3. 2&PQ��,�
1����������
1. 1�2�y�����x�������
2. 1�2�y����f-���! �|
3. 1�2�y������,+w���+��nj
4. 1�2�y� febrile convulsion
Case Study
RDE'T%!8Q�4+#!, 18 'a ����0�1#CC : &��5"+!$0g��# 1 ��\+�PI : Case CPS �# 2 'a �#�8-,2#� hippocampal sclerosis ���1#�E%! valproic acid 1500 ��./%��, carbamazepine 1200 ��./%�� *%5*,�+#�#�K�E� 7-" 2 ��\+�� IR"#��#� +#�#�&��5"+!�#�$0g� 1-2 *��g4-"+%�� 7�"204�#K'�57��!.��,4����8#�*� -�%2�(��5!#�5%"# +!D"H��(��5�D4-#�� I-E+4�#�204���I�!#���&��&���� I 3 *\+ lamotrigine 7-"+#�#�K�"� $0g� 204�#�#-�%2� I 3�4�!#5#/�� �*�����.
Problem
New onset of intractable seizure
Patient with chronic and
active epilepsy
1. Review diagnosis and etiology
� history
� EEG
� neuroimaging
� other investigation
2. Classify epilepsy
3. Review compliance
15
History
1. �+5'�(2J#��\+�$#��# 2 ��\+�
2. Urine pregnancy test: positive
3. Abortion
HM��R&* 28 �T Q#U����V+ 35 !#�O�H+
Epilepsy 2 �T,well controlled with CBZ
GTC 3 ��#U� H3#���-��3'%*� CBZ PB
()&*+X�-���V+(�Y�Z�IH0��3'%*�
��/�w����
�LMH�
1. �����N0�I��-'%*�-# *�&'%&��
2. -�����(.���, ��#�
��������
1. 1�2�y���������� l������
2. �����1���������
N0,)����[�
1. -��O/(3./0�1�*2��3�4#-&'%Q#U����V+
2. .3N,�2��3�4#-Q\,-��Q#U����V+
3. -����# ��3'%*�*�
Complications of Pregnancy in Epilepsy
Bleeding
Premature separation of the placenta
Toxaemia of pregnancy and pre-eclampsia
Miscarriage
Intrauterine growth retardation, low birth weight
Still birth and perinatal mortality
16
Complications of Pregnancy in Epilepsy
Premature labour
Breech and other abnormal presentations
Forceps delivery, induced labour, Caesarean sectionPrecipitant labour
Psychiatric disturbance
Management in Pregnancy
1. Monotherapy
2. R�\Q0,���3'%*�*� AED
3. Vit B ���(3Y Folic acid 5 �-./�#�
4. Valproate/ carbamazepine
- ultrasound 16-18 wk
- alpha fetroprotein
5. -\,��3,O 1 wk
- admit
- Vit K1 20 �-./�#�
6. Drug level
7. Normal labor, except SE
Management in Pregnancy
4�*R&* 30, nephrotic syndrome 3 �Ob,�, alb 2.2 gm/dL�#-P�O0�* prednisolone RO0.3R�\O'R,�����3b,O (3Y 2nd GTC 3 ��#U�Pulmonary TB, AFB positiveCT-brain: granulomatous lesionAnti TB drug: IRZE + phenytoin 300 mg/day4#-dUZ� Q����YO# *�RO0 12 ug/dLPhenytoin ���� 400 mg/day3 �#�Q\,���',�-�������'*� �O���d nystagmus, cerebellar sign
-�['ef-P� N0,)����[�
1. N0, \�4'U-��Q����YO# *�
2. N0,����Y�#�I�./0�1�* hypoalbuminemia,
renal disease
3. Drug interaction:anti TB drug vs AEDs
4. -����# *� phenytoin
17
Indications for Serum Level Monitoring
1.Poor response : to identify unusual pharmacokineticpatterns or poor compliance
2.Physiological or pathological conditions: changing pharmacokinetics(hepatic disease,kidney disease,pregnancy, )
3.Establishing drug toxicity
Indications for Serum Level Monitoring
4.Minimizing the problems caused by
non-linear kinetics with phenytoin
5.Minimizing the problems caused by
drug interactions
Hypoalbumin
Corrected phenytoin level 22
( ) 1.0/4.4
0.1 -1
ionconcentrat observed
+
×
=
dlgm
albPH
Phenytoin
CYP2C9 > CYP2C19
HPPH
glucuronide
Urine
Inducer(rifampin, CBZ)
Inhibitor (INH,cimetidine, omeprazole)
300 mg
325 mg
330 mg
350 mg