CME: Guidelines for Treating First Seizure

CME: Guidelines for Treating First Seizure
Author Information (click to view)

Allan Krumholz, MD

Allan Krumholz, MD
Professor of Neurology
University of Maryland School of Medicine
Director
University of Maryland Epilepsy Center

Allan Krumholz, MD, has indicated to Physician’s Weekly that he serves on the editorial board for Clinical EEG and Neuroscience, and has received royalties from UpToDate.

Figure 1 (click to view)
Target Audience (click to view)

This activity is designed to meet the needs of physicians.

Learning Objectives(click to view)

Upon completion of the educational activity, participants should be able to:

 

  1. Review the 2015 update to the American Academy of Neurology and American Epilepsy Society evidence-based guidelines on prognosis and therapy for first seizures, particularly in regard to conveying recurrence risk to patients and initiating antiepileptic drug therapy.
  2. Discuss topics within first seizure diagnosis and management that require future research to better understand.

Method of Participation(click to view)

Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation.  A statement of credit will be available upon completion of an online evaluation/claimed credit form at www.akhcme.com/pwFeb1.  You must participate in the entire activity to receive credit.  If you have questions about this CME/CE activity, please contact AKH Inc. at dcotterman@akhcme.com.

Credit Available(click to view)


AKH

CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare

Physicians

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s.  AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.

 

AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Commercial Support(click to view)

There is no commercial support for this activity.

Disclosures(click to view)

It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.

Disclosure of Unlabeled Use & Investigational Product(click to view)

This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer(click to view)

This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.

Faculty & Credentials(click to view)

FACULTY DISCLOSURES

Keith D’Oria – Editorial Director
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Allan Krumholz, MD
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
 AKH and PHYSICIAN WEEKLY’S STAFF/REVIEWERS

Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.

AKH planners and reviewers have no relevant financial relationships to disclose.

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Allan Krumholz, MD (click to view)

Allan Krumholz, MD

Allan Krumholz, MD
Professor of Neurology
University of Maryland School of Medicine
Director
University of Maryland Epilepsy Center

Allan Krumholz, MD, has indicated to Physician’s Weekly that he serves on the editorial board for Clinical EEG and Neuroscience, and has received royalties from UpToDate.

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The American Academy of Neurology and the American Epilepsy Society have released a guideline on managing adult patients who suffer a first seizure. Decisions to treat patients after these events are complex, highlighting the need to consider risks and benefits for each individual.
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According to current estimates, about 150,000 American adults present with an unprovoked first seizure each year. Studies show that even one seizure can be a traumatic physical and psychological event for patients. They can have major consequences for patients, including loss of driving privileges, employment limitations, a higher risk for falls, and fears of having another seizure in public. Recurrent seizures can be even more serious and costly.

Unprovoked first seizures are difficult to for clinicians to diagnose and treat. In 2007, practice guidelines were released to help clinicians evaluate an unprovoked first seizure in adults. In 2015, the American Academy of Neurology and the American Epilepsy Society issued evidence-based guidelines on prognosis and therapy for first seizures. This guideline, published in Neurology and available for free at www.neurology.org, clarifies when risk factors put individuals at greater risk for seizure recurrence. Prevention of seizure recurrence with antiepileptic drug (AED) therapy is also discussed.

“Evidence-based approaches are needed to evaluate and manage adults after a first seizure,” says Allan Krumholz, MD, who was lead author of the guideline. “This guideline is a valuable tool because it could change approaches to treating first seizures, enabling clinicians to possibly improve outcomes and quality of life in patients.”

Conveying Recurrence Risk

The guidelines offer recommendations regarding the risk of seizure recurrence among patients who have an unprovoked first seizure. “Adults who have an unprovoked first seizure should be informed that their seizure recurrence risk is greatest early within the first 2 years,” Dr. Krumholz says. Studies show that recurrence risks vary between 21% and 45%, depending on a variety of factors (Figure).

Several variables have been linked to increased risk of seizure recurrence. “These include a prior brain insult, an EEG with epileptiform abnormalities, a significant brain-imaging abnormality, and a nocturnal seizure,” explains Dr. Krumholz. The table below depicts the causes of seizures and their relative rate increases for seizure recurrence over time:

Seizure cause  Rate increase Years
Prior brain insult 2.55 1 to 5 years
EEGs with epileptiform abnormalities 2.16 1 to 5 years
Abnormal brain imaging 2.44 1 to 4 years
Nocturnal seizure 2.10 1 to 4 years

Clinical variables that have not been consistently associated with an increased recurrence risk of seizures after an unprovoked first seizure in adults include age, sex, family history of seizures, seizure type, and presentation with status epilepticus or multiple discrete seizures within 24 hours with recovery between them.

Initiating AED Therapy

The guidelines note that immediate AED therapy is likely to reduce seizure recurrence risk within the first 2 years of a first seizure when compared with delaying treatment pending a second seizure. “AED therapy is important to reducing subsequent risks, but clinicians should caution patients that it may not improve their quality of life,” says Dr. Krumholz. “In addition, patients should be informed that immediate AED treatment is unlikely to improve prognoses beyond 3 years. They should also be advised that their risk of adverse events from AED use ranges from 7% to 31%, but these events are mild in nature and may be reversible in many cases.”

The decision on whether or not to initiate immediate AED treatment after a first seizure should be based on individualized assessments, according to the guidelines. “Initiating AED therapy is not a black-and-white treatment decision,” says Dr. Krumholz. “Individualized assessments should weigh the risk of recurrence against the adverse events of AED therapy. They should also consider patient preferences. Clinicians should advise their patients that immediate treatment will not improve the long-term prognosis for seizure remission, but will likely reduce seizure risks over the next 2 years.”

Future Research

Dr. Krumholz notes that there is still much to learn regarding the optimal management of patients who suffer an unprovoked first seizure. The guidelines note that data are needed to determine when, how, and by whom patients would be best advised regarding driving, employment, and other social issues after a first seizure. More research is also needed on patient preferences, psychosocial factors, and quality-of-life measures. This information will then need to be incorporated into decision-making processes.

Studies are also lacking on the degree to which AED treatment  may influence the risk of seizure recurrence based on the specific known clinical factors that increase risk (Table) taken individually or when considered in combination. Updated studies utilizing newer AEDs for initial therapy are also warranted and encouraged. “For now, clinicians should use these guidelines to assist them when making decisions on whether to immediately treat a first seizure,” says Dr. Krumholz. “This requires meaningful conversations between patients and doctors so that all of the variables can be accounted for and discussed.”

Readings & Resources (click to view)

Krumholz A, Wiebe S, Gronseth G, et al. Evidence-based guideline: management of an unprovoked first seizure in adults: report of the guideline development subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology. 2015;84:1705-1713. Available at: http://www.neurology.org/content/84/16/1705.full.

Hauser W, Beghi E. First seizure definitions and worldwide incidence and mortality. Epilepsia. 2008;49(suppl):8-12.

Krumholz A, Wiebe S, Gronseth G, et al. Practice parameter: evaluating an apparent unprovoked first seizure in adults (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology. 2007;69:1996-2007.

Hesdorffer D, Benn E, Cascino G, Hauser W. Is a first acute symptomatic seizure epilepsy? Mortality and risk for recurrent seizure. Epilepsia. 2009;50:1102-1108.

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