Care Management for Patients with Epilepsy

Edward Faught, MD, professor of neurology, Emory University School of Medicine, and director, Emory Epilepsy Program, gave a presentation titled Epilepsy: Diagnosis, Treatment, and Levels of Care in a session in the Health Management II track. The presentation provided basic facts about epilepsy, information on drugs used in treatment of patients with epilepsy, levels of care, new technologies for diagnosis and surgery, and the future of epilepsy care.

Epilepsy is defined as ≥2 unprovoked seizures or one unprovoked seizure with at least a 70% chance of recurrence. There are approximately 50 patients per 100,000 individuals diagnosed with epilepsy each year (43 in developed countries; 80+ in developing countries). There are two categories of seizures: (1) focal; seizures that start in one part of the brain, from a focal lesion; most common in adults; (2) generalized; seizures that start bilaterally in the brain; most common in children; usually genetic.

The costs of care, both direct and indirect, are high. Patients often experience comorbidities; seizures may result in injury or death (SUDEP—sudden death in epilepsy). Epilepsy often leads to psychosocial problems and “even an occasional seizure can be devastating socially and psychologically,” Dr. Faught said.

Current treatment recommendations call for medications (100% of patients), surgery (10% of patients, one in three can stop medications); electrical neuromodulation, either extracranial (vagal nerve stimulator) or intracranial (responsive neurostimulator); and ketogenic diets (1% of patients, mostly children).

Dr. Faught described the four levels of epilepsy care:

• Initial diagnosis and treatment, including decisions regarding choice of medication. Popular medications for first-line therapy include levetiracetam, carbamazepine, lamotrigine, or topiramate.
• Neurologist care, should be involved within 3 months of seizure onset. The neurologist will order an epilepsy-specific MRI and an EEG, and adjust medication based on serum levels. Consideration regarding addition of a second drug will also be made.
• Epileptologist care provides an additional level of experience in epilepsy or clinical neurophysiology and enhanced knowledge of second-level drugs.
• Comprehensive epilepsy center care is commonly available at academic medical centers and provides patient access to neuropsychology, rehabilitation, and social services, as well as management of unusual drugs and clinical trials of experimental drugs.

Addressing the question of which antiepileptic drugs should be on the formulary, Dr. Fraught noted that step therapy does not work due to variation and unpredictability of individual response. “Formularies should contain commonly used drugs and probably at least one drug from each category of mechanism of action. Drugs with the same mechanism of action are not necessarily redundant because nearly all antiepileptic drugs have more than one mechanism of action, often unknown,” he said.

Dr. Fraught continued with a discussion on surgical therapy for epilepsy. Surgical therapy should be considered when ≥2 appropriate antiepileptic drugs have failed and is highly effective for selected patients with focal seizures. Sixty percent to 80% of patients are seizure-free following surgery for temporal lobe foci; 40% to 60% have positive results after surgery for other brain locations.

The session concluded with a brief overview of future directions for epilepsy care, including more minimally invasive surgery (laser, radiofrequency), gene therapy, personalized medicine, and medication to prevent epilepsy.

2017. Edward Faught, MD. Clinical Insights into the Diagnosis and Treatment of Epilepsy. 2017 Fall Managed Care Forum. October 27, 2017.