SIGN 143 • Diagnosis and management of epilepsy in adults A national clinical guideline May 2015 · Revised 2018 Eviden ce KEY TO EVIDENCE STATEMENTS AND GRADES OF RECOMMENDATIONS LEVELS OF EVIDENCE 1++ High-quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias 1+ Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias 1 - Meta-analyses, systematic reviews, or RCTs with a high risk of bias High-quality systematic reviews of case-control or cohort studies 2++ High-quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal Well-conducted case-control or cohort studies with a low risk of confounding or bias and a moderate probability that the 2+ relationship is causal 2 - Case-control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal 3 Non-analytic studies, eg case reports, case series 4 Expert opinion GRADES OF RECOMMENDATION Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation. At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or A A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results A body of evidence including studies rated as 2++, B directly applicable to the target population, and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 1++ or 1+ A body of evidence including studies rated as 2+, C directly applicable to the target population and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 2++ Evidence level 3 or 4; or D Extrapolated evidence from studies rated as 2+ GOOD PRACTICE POINTS  Recommended best practice based on the clinical experience of the guideline development group NHS Evidence has accredited the process used by Scottish Intercollegiate Guidelines Network to produce guidelines. Accreditation is applicable to guidance produced using the processes described in SIGN 50: a guideline developer’s handbook, 2008 edition (www.sign.ac.uk/guidelines/fulltext/50/index.html). More information on accreditation can be viewed at www.evidence.nhs.uk Healthcare Improvement Scotland (HIS) is committed to equality and diversity and assesses all its publications for likely impact on the six equality groups defined by age, disability, gender, race, religion/belief and sexual orientation. SIGN guidelines are produced using a standard methodology that has been equality impact assessed to ensure that these equality aims are addressed in every guideline. This methodology is set out in the current version of SIGN 50, our guideline manual, which can be found at www.sign.ac.uk/guidelines/fulltext/50/index.html. The EQIA assessment of the manual can be seen at www.sign.ac.uk/pdf/sign50eqia.pdf. The full report in paper form and/or alternative format is available on request from the Healthcare Improvement Scotland Equality and Diversity Officer. Every care is taken to ensure that this publication is correct in every detail at the time of publication. However, in the event of errors or omissions corrections will be published in the web version of this document, which is the definitive version at all times. This version can be found on our web site www.sign.ac.uk. This document is produced from elemental chlorine-free material and is sourced from sustainable forests. Scottish Intercollegiate Guidelines Network Diagnosis and management of epilepsy in adults A national clinical guideline Revised 2018 Diagnosis and management of epilepsy in adults Scottish Intercollegiate Guidelines Network Gyle Square, 1 South Gyle Crescent Edinburgh EH12 9EB www.sign.ac.uk First published May 2015 Updated September 2018 ISBN 978 1 909103 34 4 Citation text Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of epilepsy in adults. Edinburgh: SIGN; 2015. (SIGN publication no. 143). [May 2015]. Available from URL: http://www.sign.ac.uk SIGN consents to the photocopying of this guideline for the purpose of implementation in NHSScotland. Diagnosis and management of epilepsy in adults Contents Contents 1 Introduction ......................................................................................................................................................................1 1.1 The need for a guideline ......................................................................................................................................................................1 1.2 Remit of the guideline ..........................................................................................................................................................................2 1.3 Statement of intent ................................................................................................................................................................................2 2 Key recommendations ....................................................................................................................................................4 2.1 Diagnosis ...................................................................................................................................................................................................4 2.2 Treatment ..................................................................................................................................................................................................4 2.3 Management of prolonged seizures including status epilepticus ........................................................................................4 2.4 Epilepsy and women’s health .............................................................................................................................................................5 2.5 Psychiatric comorbidity ........................................................................................................................................................................5 2.6 Mortality .....................................................................................................................................................................................................5 2.7 Models of care ..........................................................................................................................................................................................5 3 Diagnosis ...........................................................................................................................................................................6 3.1 Who should make the diagnosis of epilepsy? ..............................................................................................................................6 3.2 Definition and classification ................................................................................................................................................................6 3.3 Clinical factors and diagnosis .............................................................................................................................................................8 3.4 Use of EEG in the diagnosis and classification of epilepsy .......................................................................................................9 3.5 Hand-held video......................................................................................................................................................................................11 3.6 Brain imaging ...........................................................................................................................................................................................11 3.7 Electrocardiography ..............................................................................................................................................................................11 3.8 Genetic testing.........................................................................................................................................................................................12 4 Treatment ..........................................................................................................................................................................13 4.1 When to start antiepileptic treatment ............................................................................................................................................13 4.2 Antiepileptic drug monotherapy ......................................................................................................................................................13 4.3 Management of drug-resistant epilepsy ........................................................................................................................................14 4.4 Antiepileptic drug blood levels .........................................................................................................................................................16 4.5 Management of provoked seizures ..................................................................................................................................................17 4.6 Antiepileptic drug adverse effects ....................................................................................................................................................17 4.7 Antiepileptic drug withdrawal ...........................................................................................................................................................19 4.8 Complementary therapy ......................................................................................................................................................................20 4.9 Surgical referral ........................................................................................................................................................................................23 4.10 Management of prolonged seizures including status epilepticus .........................................................................................23 4.11 Patients with recurrent prolonged or serial seizures in the community ............................................................................26 4.12 Drugs which exacerbate epileptic seizures ...................................................................................................................................27 4.13 Management of patients with epilepsy in the perioperative period ...................................................................................27 4.14 Management of older people with epilepsy ................................................................................................................................27 4.15 Management of people with learning disability and epilepsy ..............................................................................................29 5 Epilepsy and women’s health ........................................................................................................................................31 5.1 Contraception ..........................................................................................................................................................................................31 5.2 Preconceptual counselling ..................................................................................................................................................................35 5.3 Risks of inheriting epilepsy ..................................................................................................................................................................36 5.4 Pregnancy ..................................................................................................................................................................................................38 5.5 Labour and birth .....................................................................................................................................................................................40 DDiiaaggnnoossiiss aanndd mmaannaaggeemmeenntt ooff eeppiilleeppssyy iinn aadduullttss 5.6 Fetal, neonatal and childhood outcomes ......................................................................................................................................43 5.7 Postpartum advice for mothers .........................................................................................................................................................47 5.8 Advice about breastfeeding ...............................................................................................................................................................48 5.9 Menopause and epilepsy .....................................................................................................................................................................49 6 Psychiatric comorbidity ..................................................................................................................................................50 6.1 Screening ...................................................................................................................................................................................................50 6.2 Treatment options ..................................................................................................................................................................................52 7 Sleep ...................................................................................................................................................................................54 7.1 Sleep deprivation and sleep hygiene ..............................................................................................................................................54 7.2 Obstructive sleep apnoea and epilepsy .........................................................................................................................................54 7.3 Sudden unexpected death in epilepsy and sleep .......................................................................................................................54 8 Mortality ............................................................................................................................................................................55 8.1 Sudden unexpected death in epilepsy ...........................................................................................................................................55 9 Models of care ..................................................................................................................................................................57 9.1 Models of primary care for epilepsy .................................................................................................................................................57 9.2 Models of secondary and tertiary care for epilepsy ...................................................................................................................59 9.3 Role of the epilepsy specialist nurse ................................................................................................................................................61 9.4 Self management....................................................................................................................................................................................62 10 Provision of information.................................................................................................................................................63 10.1 Advice and information on epilepsy ................................................................................................................................................63 10.2 Checklist for provision of information .............................................................................................................................................64 10.3 Sources of further information ..........................................................................................................................................................65 11 Implementing the guideline ..........................................................................................................................................69 11.1 Implementation strategy .....................................................................................................................................................................69 11.2 Resource implications of key recommendations ........................................................................................................................69 11.3 Auditing current practice .....................................................................................................................................................................69 11.4 Additional advice to NHSScotland from Healthcare Improvement Scotland and the Scottish Medicines Consortium .........................................................................................................................................................69 12 The evidence base ...........................................................................................................................................................72 12.1 Systematic literature review ................................................................................................................................................................72 12.2 Recommendations for research.........................................................................................................................................................72 12.3 Review and updating ............................................................................................................................................................................73 13 Development of the guideline ......................................................................................................................................74 13.1 Introduction ..............................................................................................................................................................................................74 13.2 The guideline development group ..................................................................................................................................................74 13.3 Consultation and peer review ............................................................................................................................................................76 Abbreviations ................................................................................................................................................................................78 Annexes ..........................................................................................................................................................................................80 References......................................................................................................................................................................................84 DDiiaaggnnoossiiss aanndd mmaannaaggeemmeenntt ooff eeppiilleeppssyy iinn aadduullttss 1 • Introduction 1 Introduction 1.1 THE NEED FOR A GUIDELINE Since the publication of SIGN 70 in 2003 there has been an expansion in the number of epilepsy specialists, and improved and faster access to clinics devoted to epilepsy and first seizures. The number of drugs available to treat epilepsy has increased and the range of imaging, surgical and interventional techniques has risen. Collectively, these changes have helped to bring about the improvements in care highlighted as necessary in the previous guideline. Despite these improvements, however, the scale and scope of the need for a guideline should not be underestimated. In Scotland there are 54,000 people with active epilepsy affecting all ages,1, 2 and there will be between 2,000 and 3,500 new diagnoses each year.1 The low number of epilepsy specialists in previous decades means that many people with epilepsy across the UK have been diagnosed and treated by non-specialists in both primary and secondary care. Up to a quarter of patients referred for specialist management of apparent drug-resistant epilepsy do not have epilepsy and around 50% of referrals to first seizure clinics result from events which are not epileptic. There is evidence that management can sometimes be suboptimal,3-5 and with some intervention, readily improved.3, 5 Epilepsy carries a small but significant risk of mortality which is increased where seizure control is incomplete. Specific concerns surround initial diagnosis, drug treatment, management of pregnant women with epilepsy and the provision of patient information. It is likely that the incidence of sudden unexpected death in epilepsy (SUDEP) could be reduced if antiepileptic treatment was always optimised and patients made aware of the importance of adherence. There is room for improvement in the diagnosis and management of status epilepticus and in the care and advice provided for women of reproductive age. People with epilepsy often report inadequate provision of information and advice. Such needs were highlighted in the previous guideline and, over ten years on, there remains scope for the development of better epilepsy services in both primary and secondary care. 1.1.1 UPDATING THE EVIDENCE This guideline updates SIGN 70: Diagnosis and management of epilepsy in adults to reflect the most recent evidence. Where no new evidence was identified to support an update, text and recommendations are reproduced verbatim from SIGN 70. The original supporting evidence was not reappraised by the current guideline development group. 1.1.2 SUMMARY OF UPDATES TO THE GUIDELINE, BY SECTION In September 2018, this guideline was updated to take account of new drug safety advice from the Medicines and Healthcare products Regulatory Agency (MHRA), published in April 2018, relating to use of valproate medicines in women and girls of childbearing potential.454 Warnings have been inserted where relevant in sections 4 and 5 to reflect this advice. 2 Key recommendations New 3 Diagnosis Updated 4 Treatment Updated September 2018 5 Epilepsy and women’s health Updated September 2018 6 Psychiatric comorbidity New 7 Sleep New 8 Mortality New 9 Models of care Completely revised 10 Provision of information Completely revised 11 Implementing the guideline Completely revised 12 The evidence base Completely revised | 1 Diagnosis and management of epilepsy in adults 1.2 REMIT OF THE GUIDELINE 1.2.1 OVERALL OBJECTIVES This guideline provides recommendations based on current evidence for best practice in the diagnosis and management of epilepsy in adults. It does not include patients with a non-epileptic attack disorder (see section 3.3.1). 1.2.2 TARGET USERS OF THE GUIDELINE This guideline will be of interest to all health professionals in primary and secondary care involved in the management of people with epilepsy, including general practitioners, practice nurses, epilepsy specialist nurses, general physicians, emergency department specialists, neurologists, obstetricians, clinical neuropsychologists and psychiatrists. It will also be of interest to those commissioning epilepsy services, public-health physicians, pharmacists, social-work staff, carers and relatives of people with epilepsy and people with epilepsy themselves. 1.3 STATEMENT OF INTENT This guideline is not intended to be construed or to serve as a standard of care. Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns of care evolve. Adherence to guideline recommendations will not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgement must be made by the appropriate healthcare professional(s) responsible for clinical decisions regarding a particular clinical procedure or treatment plan. This judgement should only be arrived at following discussion of the options with the patient, covering the diagnostic and treatment choices available. It is advised, however, that significant departures from the national guideline or any local guidelines derived from it should be fully documented in the patient’s case notes at the time the relevant decision is taken. 1.3.1 PRESCRIBING OF LICENSED MEDICINES OUTWITH THEIR MARKETING AUTHORISATION Recommendations within this guideline are based on the best clinical evidence. Some recommendations may be for medicines prescribed outwith the marketing authorisation (MA) also known as product licence. This is known as ‘off-label’ use. Medicines may be prescribed off label in the following circumstances: y for an indication not specified within the marketing authorisation y for administration via a different route y for administration of a different dose y for a different patient population. An unlicensed medicine is a medicine which does not have MA for medicinal use in humans. Generally off-label prescribing of medicines becomes necessary if the clinical need cannot be met by licensed medicines within the marketing authorisation. Such use should be supported by appropriate evidence and experience.6 “Prescribing medicines outside the conditions of their marketing authorisation alters (and probably increases) the prescribers’ professional responsibility and potential liability”.6 2 | Diagnosis and management of epilepsy in adults 1 • Introduction The General Medical Council recommends that when prescribing a medicine off label, doctors should: y be satisfied that such use would better serve the patient’s needs than an authorised alternative (if one exists) y be satisfied that there is sufficient evidence/experience of using the medicines to show its safety and efficacy, seeking the necessary information from appropriate sources y record in the patient’s clinical notes the medicine prescribed and, when not following common practice, the reasons for the choice, and y take responsibility for prescribing the medicine and for overseeing the patient’s care, including monitoring the effects of the medicine. Non-medical prescribers should ensure that they are familiar with the legislative framework and their own professional prescribing standards. Prior to any prescribing, the licensing status of a medication should be checked in the summary of product characteristics (www.medicines.org.uk). The prescriber must be competent, operate within the professional code of ethics of their statutory bodies and the prescribing practices of their employers.7 1.3.2 ADDITIONAL ADVICE TO NHSSCOTLAND FROM HEALTHCARE IMPROVEMENT SCOTLAND AND THE SCOTTISH MEDICINES CONSORTIUM Healthcare Improvement Scotland processes multiple technology appraisals (MTAs) for NHSScotland that have been produced by the National Institute for Health and Care Excellence (NICE) in England and Wales. The Scottish Medicines Consortium (SMC) provides advice to NHS boards and their Area Drug and Therapeutics Committees about the status of all newly licensed medicines and any major new indications for established products. SMC advice relevant to this guideline is summarised in section 11.4. | 3 Diagnosis and management of epilepsy in adults 2 Key recommendations The following recommendations were highlighted by the guideline development group as the key clinical recommendations that should be prioritised for implementation. The grade of recommendation relates to the strength of the supporting evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation. 2.1 DIAGNOSIS C The diagnosis of epilepsy should be made by an epilepsy specialist. C A clear history from the patient and an eyewitness to the attack give the most important diagnostic information, and should be the mainstay of diagnosis. 2.2 TREATMENT Antiepileptic drugs should be offered after a first tonic-clonic seizure if: B y the patient has had previous myoclonic, absence or focal seizures B y the EEG shows unequivocal epileptic discharges B y the patient has a structural cerebral disorder D y the patient considers the risk of recurrence unacceptable. C Routine switching between different manufacturers of antiepileptic drugs should be avoided. C Failure to respond to appropriate antiepileptic drugs should prompt a review of the diagnois of epilepsy and adherence to medication. B Referral for assessment for neurosurgical treatment should be considered if the epilepsy is drug resistant. D EEG should be used for confirming diagnosis of and monitoring treatment effects in patients with status epilepticus. EEG should be available as an emergency intervention for all patients with treated or suspected status epilepticus. 2.3 MANAGEMENT OF PROLONGED SEIZURES INCLUDING STATUS EPILEPTICUS  As soon as possible: y secure airway y give oxygen y assess cardiac and respiratory function y secure IV access in large veins. B Patients with prolonged tonic-clonic seizures that have lasted five minutes or more should be given: y midazolam 10 mg buccally or intranasally, or y lorazepam 4 mg IV if midazolam is unavailable, or y diazepam 10 mg if midazolam and lorazepam are unavailable. B Administer a repeat dose of benzodiazepine in hospital after 10 minutes if there is no response. 4 |