Monthly Case

Awakening with tapering of antiepileptics | 1-2014

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A 39-year old female patient with childhood onset epilepsy was admitted to the Epilepsy-Center Berlin-Brandenburg due to intense tiredness, desorientation und impaired speech production. The patient suffers from learning disability, she lives in assisted accommodation. She has partial epilepsy, automotor (= complex partial) seizures with impaired consciousness and oral automatisms are reported to manifest every 2-3 months. The cause of epilepsy is unclear, a cMRT from 2011 is normal.

In the weeks prior to admittance, the patient has slept most of the time und she was almost unable to walk. She was brought onto the ward with a stretcher.

The treatment regimen consisted of five antiepileptic drugs: primidone, carbamazepine, zonisamide, clobazam and valproic acid. On admission, serum concentration of valproic acid was markedly elevated to 130 mg/l (normal range, 40 – 100 mg/l).

The aim of our treatment was to taper some of the antiepileptic drugs without facilitating increase in seizure frequency. Step by step, we reduced and eventually withdrew the substances zonisamide, clobazam and valproic acid. As the patient was administered primidone for more than 30 years, we refrained from withdrawal of this – also potentially sedating – antiepileptic drug due to risk of rebound seizures.

During four weeks of treatment and tapering of antiepileptic drugs in our center, the patient “woke up”, with physiotherapeutic support she re-learned to walk unassisted und she spoke spontaneously. We did not observe increased seizure frequency.

This case demonstrates impressively, that regular review of antiepileptic drug regimen by epilepsy specialists is urgently needed. In this particular patient, all medical troubles – tiredness and incapacity to walk and speak – had to be traced back to overtreatment with five antiepileptic drugs. Generally, even intractable epilepsies should not be treated with more than two antiepileptics. Clinical trials have demonstrated that administration of a third substance does not have any effect on seizure frequency and severity, but significantly increases the risk for non-tolerable side-effects.

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