Recommendations for Epilepsy Care During COVID-19

Jacqueline A. French, MD

Recommendations created by an international group of epilepsy specialists seek to optimize care for people with epilepsy during the COVID-19 pandemic.

The recommendations, published in Neurology, include an emphasis on as much care as possible in an at-home setting to keep people with epilepsy out of health care facilities, as well as minimizing risk of seizure exacerbation through treatment adherence and ensuring a regular supply of medication.

The authors, led by Jacqueline French, MD, professor of neurology at NYU Grossman School of Medicine, director of epilepsy research and epilepsy clinical trials, NYU Langone Health’s Comprehensive Epilepsy Center, developed consensus statements in 2 sections with the goal of providing information on the impact of COVID-19 on people with epilepsy, as well as recommendations on maximizing the best possible care for people with epilepsy while avoiding visits to urgent care facilities and hospitals. The 2 sections covered modifications to the clinical care pathway, as well as general advice for people with epilepsy in light of the pandemic.

Statements addressing common questions and concerns from the epilepsy community were formulated and provided to each of the authors for scoring. The scoring was done on a scale of -10 (strongly disagree) to +10 (strongly agree). Ultimately, all consensus recommendations were scored as a 7 or above.

Questions and recommendations included:

Does SARS-COVID-2 precipitate or aggravate existing seizures?

While there is limited evidence that the central nervous system (CNS) is a target of SARS-COVID-2, the virus’ penchant for ACE2 receptors may make CNS glia and neurons a target. While it is unclear to what degree the virus penetrates the blood-brain barrier, it has been suggested that it may penetrate the brainstem, contributing to respiratory impairment. Neurologic manifestations including seizures are more likely to reflect COVID-19-related hypoxia, encephalopathy, or encephalitis, and some new-onset seizures have been reported earlier in the disease course.

Are people with epilepsy more predisposed (or vice versa) to COVID-19 infection?

Available data, albeit limited, does not suggest that people with epilepsy are more likely to be infected or have more severe COVID-19 disease. Patients with tuberous sclerosis complex may have reduced lung function and may be treated with immune therapy, and therefore may be a greater risk. Similar risks may be observed in patients with autoimmune disorders and epilepsy who may be receiving immunosuppressant therapy, as well as those with syndromes like Dravet syndrome, where seizures may be aggravated by fever or illness. Overall, there have been no reports of worsening conditions in patients who have been exposed to COVID-19, and children in general are less likely to suffer from severe respiratory illness.

Are there medications that should be avioded in people with epilepsy?

It has been suggested that certain medications including nonsteroidal anti-inflammatory drugs (NSAIDS) should be avoided in the acute phase of infection. Acetaminophen (paracetamol) can be used for patients in whom fever control may be more important, including patients with Dravet syndrome.

“Risk to benefit ratio must be assessed in each case if these medications are considered useful,” French and colleagues concluded.

How should clinicians modify clinical care for people with epilepsy during the COVID-19 pandemic?

Along with administering as much care as possible at home, patients should have an emergency care plan in place so that rescue medication use or an emergency visit can be as structured as possible. Utilizing hospital visits should only be done in an emergency setting, so patients who suffer from tonic-clonic seizures, which typically last under 2 to 3 minutes, can be assured that emergency visits are not necessary unless seizures last more than 5 minutes or clusters, occur in water, or are followed by abnormal recovery. Stocking up on medication, as well as maintaining the need for regular sleep, consistency in current routines, eating healthy, and exercising are all recommended. Utilizing telehealth for follow-up appointments and taking thorough home videos of patients with new presentations are key.

In general, EEG monitoring and imaging should be delayed to a later date. If necessary, these should be done in an outpatient facility and risks/benefits should be weighed.

What general advice should we give to people with epilepsy during this crisis?

The authors came up with 6 general points of advice, including minimizing the likelihood of seizure exacerbation, coming up with a comprehensive care plan in case a family member or caregiver is not available in an emergency situation, and stressing daily routines and staying consistent. Patients with epilepsy should also work to prevent medication shortages and have access to telephone advice for those who suffer from mental health issues. Adequate sleep, engaging in routine exercise, eating healthy, and avoiding alcohol and recreational drugs are all recommended as well.

What are the implications for resource poor countries?

Health care systems may be inadequate to deal not only with a massive rise in number of infected cases but also with the consequences of lockdown. Telemedicine and access to medication delivery systems may be severely impacted, and it is up to health care professionals to come up with innovative solutions for these issues. which puts stress on the importance of maintaining a supply of antiseizure medications. In addition, preventive measures may also be impacted, leaving children unprotected.

Information for physicians on the matter, including updated information on the best practices for performing clinical neurophysiology testing can be found here.

REFERENCE

French JA, Brodie MJ, Caraballo R, et al. Keeping people with epilepsy safe during the COVID-19 pandemic. Neurology. Published online April 23, 2020. doi: 10.1212/WNL00000000000009632