Prominent Goals of Therapy in Epilepsy Management

Michael R. Sperling, MD: So, when we’re putting people on therapy, obviously the standard goal that we all are going to advocate is no seizures, no adverse effects. But, in the real world, that is a little tougher to accomplish. But, practically speaking, when you meet with your patients, what are the objectives that you state for them and how do you take what they tell you into consideration when planning therapy and assessing your therapy?

Jesus E. Pina-Garza, MD: I think that’s a huge point. That’s one of the times I definitely make the time because it’s very important. The person who is being initiated on treatment for epilepsy has very little knowledge about it. So, if a parent brings a kid to me, and I say we’re going to treat you for the seizures and I don’t explain it further, they expect the seizures will stop with that treatment. And we know the reality of epilepsy depends on the type. The possibilities of seizure freedom may be somewhere between 70% and 80%, whether it’s focal or generalized. So we have to tell them that this is a reality and it depends on how much information we have. If we have a healthy developing brain with a normal MRI [magnetic resonance imaging], maybe we will have a great chance. If we have a very traumatic injury with herpes encephalitis in both parts of the brain, the epileptogenicity may be hard to fully stop it. But the reality is, the goal is always to make someone seizure-free. That is not always something you can accomplish. And I used to tell my residents, remember that you cannot make everybody seizure-free, but you can make everybody sick. So you have to keep that in mind, so that you can actually treat patients with the best possible control.

Michael R. Sperling, MD: My statement to my residents and Fellows is that it’s very easy to make someone worse. It’s a lot harder to make them better. It’s the same idea. I view one of the main missions as warning people about potential adverse effects, not to excess or else they’ll develop them perhaps, but I warn them and really pay careful attention to adverse effects. But there’s also the goal that the patient has, too, Kate. And again, treating adults who have a job other than being a student, how do their occupations play a role in this when you’re gauging treatment and your goals of therapy? And what do you advise people?

Kathryn A. Davis, MD, MS, FAES: Of course that plays an enormous role. If a patient, for instance, is a high functioning professional, they’re going to have different goals, there will be different medications that may be more or less appropriate. They may be willing to pay more for a medication that’s not as impactful to their cognitive performance, for instance. In adults, often driving is a critical part of their livelihood. So they’re very focused on becoming free of seizures with loss of awareness, and that is a big point of discussion. And then we also have adults who have had epilepsy since early childhood and have severe cognitive impairments. And we could treat them until we harm them, but it’s often not the right thing to do and it’s impossible to make them seizure-free. So trying to balance quality of life issues with the danger of seizures is an important part of the decision making with each individual patient.

Michael R. Sperling, MD: The occupational aspects can be especially challenging in people, and I think we don’t want to overly restrict them. On the other hand, we want them to be safe, but they are adults and I think there are certain judgments. I just saw someone yesterday for the first time who is a construction worker and in the summer also does landscaping, so he’s using chainsaws and electric hedge clippers. The goal there I think first is safety.

Kathryn A. Davis, MD, MS, FAES: Exactly.

Michael R. Sperling, MD: There’s counseling about occupation.

Kathryn A. Davis, MD, MS, FAES: Right, and working with them perhaps to alter their job to make it safer, at least while you’re getting the seizures under control. But that can be a very difficult conversation because then not only are they frightened from the seizures themselves but it’s threatening their livelihood.

Trevor J. Resnick, MD: The safety and adverse effects are obviously a big part of the discussion. But what’s coming up a lot has been comorbidity issues. So, as opposed to often just talking about 1 antiepileptic drug, I try not to say there’s only 1 drug you could be on. Because if it fails, the patient thinks that now whatever you’re giving them is second best. So I tend to talk about a range of different choices that are determined, 1 by efficacy, 1 by the adverse effects, and the other is by comorbidity. And I think that’s an additional issue that comes up in terms of discussion.

Michael R. Sperling, MD: Yes, and the comorbidities especially tend to accrue as people age, so it becomes far more complex to deal with.