BREAK THROUGH SEIZURE;
A brief
overview
Prof. Reda El Badry, MD, FAAN
Asyut Univ., Egypt
LEARNING OBJECTIVES:
• Following participation in this activity, participants will be able
to:
- Define non-adherence and classify different types
of non-adherence.
- List strategies to deal with non-adherence
- Recognize common, uncommon, and rare drug-
drug interactions that might affect level of anti-seizure
medications
- Analyze the use of anti-seizure drug monitoring
while dealing with breakthrough seizures
Definition
A breakthrough seizure is one occurring after at
least 12 months seizure freedom while on
treatment.
Introduction
:
Two-thirds of people with epilepsy experience seizure-freedom with optimization of antiseizure
medications.
Breakthrough seizures interrupt the seizure-freedom in a subset of these patients
Breakthrough seizures pose the threat of injuries, unemployment, sudden death, and increased
health care costs.
Management of breakthrough seizures is of paramount importance in maintaining seizure-
freedom in medically responsive epilepsy.
During
childhood
• Breakthrough seizures occur in 40% of children with well-controlled epilepsy.
• The common reason implicated is poor compliance with antiepileptic drugs (AEDs).
• However, many children have breakthrough seizures despite regularly taking AEDs.
• Various factors such as watching television, playing video games, fever, sleep deprivation,
exertion, emotional stress; etc may be responsible for this
• Identifying seizure precipitants among children in our scenario would help in better management
of epilepsy.
• Therefore, we proposed to study the factors precipitating breakthrough seizures in children with
well-controlled epilepsy.
Breakthrough seizures might occur for a number of reasons inherent to the person’s
epilepsy, or the natural history of the condition.
Inherent factors include:
- the dose of antiepileptic drug treatment being insufficient to reduce the
seizure rate to zero
- missed doses of medication, or
- provoking factors such as emotional stress,
- sleep deprivation,
- alcohol or other recreational drugs, and TV or video games.
However, this continues to be a challenge to health care teams.
• For some people, the natural history is to develop treatment refractoriness
following a period of remission, presumably due to on-going epileptogenic processes.
Frequently, the cause of a breakthrough seizure may not be identified.
DANGER OF
BREAKTHROUGH
SEIZURES
• Some argue that breakthrough seizures are more dangerous than non-breakthrough seizures as they
are unexpected by the patient, and therefore, the person may not take appropriate precautions.
• Breakthrough seizures can have severe clinical consequences for the person they may be admitted to
hospital either as a result of the seizure, or because of injuries sustained during the seizure.
• Breakthrough seizures can take the form of status epilepticus which is associated with elevated
morbidity, and potentially mortality
• Despite the fact that breakthrough seizures are commonly seen in clinical practice, very few
publications have examined factors associated with a breakthrough seizure and outcomes following
such a seizure.
• Two papers consider breakthrough seizures among people with epilepsy in developing countries,
however similar papers for people in developed countries are lacking
WHAT ARE THE QUESTIONS
THAT SHOULD BE ANSWERED
?
What are the factors leading to loss of adherence
to or discontinuation of antiepileptic drug therapy?
• Adverse effects such as cognitive dysfunction or fatigue are commonly associated with use of
AEDs, and the occurrence of these events may compel patients to take less of their
medication
• Other adverse effects could include weight gain or sexual dysfunction—topics that patients
may be disinclined to discuss.
• Complexity in the dosing regimen may contribute to the problem.
• Language barriers can also hinder the clinician’s ability to effectively convey the importance
of adherence and dosing instructions to the patient.
• A patient’s lack of familiarity with his or her prescription plans and insurance issues can also
play a role.
• economic costs and mortality.
What would you recommend in order to reduce
the
occurrence of breakthrough seizures?
• It is intuitive that the selection of an AED would be based primarily on efficacy, and many of the
available agents are quite comparable in their efficacy.
• when selecting the optimal AED, such as potential side effects, ease and frequency of
administration, cost-effectiveness, and drug interactions.
• By familiarizing themselves with the drug information, clinicians will be better able to review the
drug characteristics with the patient and warn of potential side effects, as well as the need to
contact the physician before autonomously discontinuing the medication
What is needed in future research and drug
development to
address breakthrough seizures?
• I feel that research in this area needs to be catered toward the specific causes of breakthrough
seizures.
• For example, in the case of adherence, further studies are needed to obtain a better
understanding of the attitude and concerns of patients regarding their AEDs and what specific
factors are interfering with their achievement of optimal AED adherence.
• Studies have shown that adherence is better if dosing is less frequent, hence the value of
some extended-release formulations in promoting better adherence.
• For drug interactions, rigorous studies are needed for each agent on its introduction to the
drug regimen.
In this session,
speakers delve deeper into understanding medication non-
adherence and utilization of drug monitoring and explore
typical to rare drug interactions.
After end of today’s talks, speakers will respond to all your
inquiries