Treatment Plan

Acute management:

• Status epilepticus: buccal midazolam/rectal midazolam
• IV access if facilities are available to provide IV Lorazepam if the above two methods of administration fail

Ongoing management:

• Annual epilepsy review
• Urgent referral for adverse seizures
• Medication withdrawal consideration after 2 years of seizure-free Driving restrictions:
  • First seizure: No driving for 6 months
  • Established epilepsy: Must be seizure-free for 12 months o Medication withdrawal: No driving >6 months o Seizure during withdrawal: No driving >1 year o      Awake seizure: No driving >6 months-1 year o          Sleep seizure: No driving >1 year o   Can be licensed if >3 years since the original attack

Contraception considerations:

• Avoid sodium valproate and topiramate in pregnancy
• Enzyme-inducing antiepileptics affect contraceptive effectiveness (esp of oral C., Transdermal, Vaginal ring, Progesterone only implant):
  • phenytoin, primidone, phenobarbital, carbamazepine, topiramate o Alternative contraception: depot injections, IUDs (copper or Mirena) o Emergency contraception: copper IUD preferred (as the oral methods can interact with the enzyme-inducing anti-epileptics)
• Lamotrigine: Oestrogen-containing contraceptives reduce the effectiveness, therefore increasing the seizure activity.

Medication categories:

• Category 1: phenytoin, phenobarbital, primidone, carbamazepine
• Category 2: sodium valproate, lamotrigine, clobazam, clonazepam, topiramate
• Category 3: pregabalin, gabapentin, levetiracetam