Page 411 - ILAE_Lectures_2015

in overall median seizure frequency35. Parental global seizure severity was the only chosen
measure of quality of life in this study.

A further study35 used a RCT approach to add-on therapy in adults with learning disability
and epilepsy. This study showed a reduced seizure frequency of >30% in the topiramate
group as compared with 1% in placebo (P = 0.052).

Levetiracetam has not been trialled in a RCT design within this population. In an open study36
64 patients were given add-on levetiracetam after a three-month baseline. In this study 24
patients (38%) became seizure free and there were a further 18 responders (28%).

Pregabalin and zonisamide are relatively new to the market and it is expected that similar
case review studies will be seen soon.

Rufinamide has been studied in an RCT37 in which 138 randomised patients received
rufinamide or placebo. Significant improvements were seen in total seizure frequency, ‘drop-
attacks’ and a higher 50% responder rate. Common adverse events included somnolence and
vomiting.

Further details on both pharmacological and non-pharmacological studies can be seen in two
Cochrane reviews (please see Further reading).

Treatment choice
The decision of treatment choice for people with learning disability is broadly split into two
components. Firstly, choice should be based on seizure type, seizure syndrome, individual
patient characteristics and patient and carer choice. Patients and carers will have specific
concerns over drugs that may have cognitive or behavioural side effects. The clinician should
clearly describe these potential effects when informing patients. This can be a major concern
in those with co-existing behavioural problems, which can be at least 40% of the adult
population

Secondly, the clinician should assess remaining treatment options. People with learning
disability will often be on multiple therapies and will have tried several AEDs. It is important
to place a patient on a treatment pathway to assess what available untried epilepsy options
are available, whether previous options can be retried, and whether the current treatments can
be removed or dosage changed. A simple checklist for a clinician would be:

1. Current therapy. Can any of the AEDs be increased without unwanted side effects?
This is particularly useful if the AED has shown some evidence of efficacy. If on
polytherapy, can a drug be removed?

2. If none of the above, has the patient had all the available AEDs, including ‘new’
AEDS such as: lamotrigine, levetiracetam, pregabalin and topiramate?

3. If a patient has focal seizures, has assessment for resective surgery been considered?

4. If patient has tried all AEDs and is not candidate for resective surgery, has assessment
for vagal nerve stimulation been considered?

Making your treatment work
Applying treatment should be relatively easy in that many people with learning disability will
have carers who can aid in giving the treatment. The clinician will need to ensure that carers
are capable of giving medication and should also identify whether the patient has any
swallowing problems and can take the formulation prescribed. As a general rule caution in