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Epilepsy Care In Children: What To do When Medications Aren't Working

How to choose the most effective medication for your patient with epilepsy
Katherine Nickels

Anti-seizure medications (ASMs) are the mainstay of epilepsy treatment, but 30%-40% of people with epilepsy (PWE) continue to have seizures. ASM use should be guided by understanding ASM mechanisms of action, side effects, interactions, as well as epilepsy etiologies and syndromes.

Broad spectrum ASMs are needed unless there are only focal seizures.  It is important to avoid side effects least likely to be tolerated by specific patients, as well as avoiding those with high teratogenicity in patients with pregnancy potential. Medication interactions may require monitoring or changing doses of current medications.  

Acute symptomatic neonatal seizures are likely to respond to phenobarbital, but neonatal onset epilepsy due to genetic changes in sodium and potassium channels can respond to sodium channel blockers. Infantile epileptic spasm syndrome (IESS) requires treatment with vigabatrin- especially if patients have tuberous sclerosis complex, ACTH, or prednisolone. Dravet syndrome is due to loss of function changes in SCN1A in >85%, making it essential to avoid sodium channel blockers. Epilepsy syndrome classification can guide treatment when etiology is not fully understood. Specialty medications are approved for specific syndromes such as Lennox Gastaut syndrome.

Therefore, while the task of selecting a medication for PWE can be daunting, there are guidelines that help providers select a medication that is more likely to be beneficial and tolerated in their patients.

 

Surgical treatments for epilepsy- so much more than resection
D Keith Starnes

Focal resection or disconnection is used to treated refractory focal epilepsy, but not all patients are candidates. Use of neuromodulation is rapidly expanding. Neuromodulation uses targeted electrical impulses to alter neuronal activity. While not typically associated with seizure freedom, some neuromodulation modalities result in approximately 2/3 reduction in seizure frequency and significantly improve quality of life.  Neuromodulation is more than just vagal nerve stimulator – and is not only for focal epilepsy. Devices like responsive neurostimulation and deep brain stimulation are expanding into the pediatric population. New modalities like continuous cortical stimulation and noninvasive techniques like transcranial magnetic stimulation, transcranial direct/alternating current stimulation, and focused ultrasound are on the horizon.This talk will review the recent data on these technologies and the challenges of using them for pediatric epilepsy. Patient selection, stimulation targeting, and parameter optimization will be considered. Finally, we will look at how neurostimulation might guide epilepsy therapy in the future, as well as how we can clear the hurdles to making these technologies more accessible.