After completing this case study, the reader should be able to:
Identify necessary data to collect for patients with complex partial seizures.
Define potential drug-related problems for antiepileptic drugs.
List desired therapeutic outcomes for patients with complex partial seizures.
Based on patient characteristics, choose appropriate pharmacotherapy for treatment of partial seizures and develop a suitable care plan.
Identify key issues for a woman of childbearing potential taking antiepileptic drugs.
“My family doctor told me I should see a neurologist about my seizures.”
Peggy Livingston is a 36-year-old woman referred to the neurology clinic by her PCP for evaluation of her seizures and anticonvulsant therapy. She is enduring quite a heavy seizure burden. Her last seizure was 10 days ago, which resulted in her falling down her basement stairs. Her seizures started at a very early age, and she said no one has been able to identify why she started having seizures. She remembers having them in grade school and being confused a lot throughout her schooling. She was briefly tried on phenobarbital initially but has been on phenytoin most of her life. She has poor seizure control with no extended seizure-free periods. She has not seen a neurologist for years, if ever. She has not had any neuroimaging studies and provides no previous EEG results.
On speaking with the patient and her husband of 2.5 years, most of her events involve “blackouts” and losing track of time. Occasionally, she has “grand mal” seizures. She is more likely to have a seizure if she gets overly tired or stressed. She has no history of severe head injury with loss of consciousness, or other significant risk factors for seizures. She states that at some time in her past, she “felt really bad, almost drunk” on higher doses of phenytoin. She states that she is very adherent, although she has run out of medication more than once. Because she is having seizures, she does not drive and therefore must rely on others for transportation. This lack of independence is a major concern for Peggy.
Data gathered from reviewing her seizure calendar over the past 2 months (Fig. 65-1) suggest that she is experiencing approximately eight “small” seizures per month (complex partial seizures with no secondary generalization) and one “big” seizure per month (a secondarily generalized tonic–clonic seizure). Her interview details and her overall score on her responses to the QOLIE-31 questions show a significant impact of the seizures on her quality of life. Her scores on the energy/fatigue, seizure worry, and social function domains are especially low in comparison with a cohort of other patients with epilepsy. The score on her NDDI-E was 11, indicating that she had some mood issues, but she was not depressed. On asking if there is ...