arrow Log In to View Account     |      
HOME
Johns Hopkins Medicine
Hopkins Logo


Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Complexities of Epilepsy: Comorbidity, Quality of Life, and Treatment Effects


GOAL
To provide neurologists with the most recent information regarding the treatment of epilepsy.

TARGET AUDIENCE
This activity is designed for neurologists. No prerequisites required.

LEARNING OBJECTIVES
The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity. At the conclusion of this activity, participants should be able to:

  • Discuss the possible therapeutic benefits conferred by the psychotropic effects of antiepileptic drugs in patients with coexisting psychiatric/behavioral disorders.
  • Assess treatment needs in patients with epilepsy in the setting of head trauma and neurosurgical procedures.
  • Recognize the clinical interrelationships between epilepsy in the setting of coexisting conditions, such as headache, depression, and obesity, and their respective treatments in adults and children.
  • Evaluate 2 new quality-of-life instruments for children and adults with epilepsy.

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 category 1 credits toward the AMA Physician's Recognition Award. Each physician should claim only those credits that he/she actually spent in the activity.

The estimated time to complete this educational activity: 2 hours.

Release date: July 15, 2003. Expiration date: July 15, 2005.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of Johns Hopkins University School of Medicine name implies review of educational format design and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an unrestricted educational grant from Ortho-McNeil Pharmaceutical, Inc.

Full Disclosure Policy Affecting CME Activities:
As a sponsor accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Directors and Participating Faculty reported the following:

PROGRAM DIRECTORS

    Peter W. Kaplan, MBBS, FRCP
    Associate Professor of Neurology
    Johns Hopkins University School of Medicine
    Chairman of Neurology
    Director of Epilepsy and EEG
    Johns Hopkins Bayview Medical Center
    Baltimore, Maryland
    • Dr Kaplan reports receiving grant and/or research support from GlaxoSmithKline, Marion Merrill Dow, Pfizer, Inc, and UCB Pharma; serving as a consultant to Abbott Laboratories, Elan Corporation, GlaxoSmithKline, Novartis Corporation, Ortho McNeil Pharmaceutical, Inc, Pfizer, Inc, and UCB Pharma; and serving on the speaker's bureau for Abbott Laboratories, GlaxoSmithKline, Novartis Corporation, Pfizer, Inc, and UCB Pharma.

    Eileen P. G. Vining, MD
    Professor of Neurology and Pediatrics
    Johns Hopkins University School of Medicine
    Director, Pediatric Epilepsy Center
    Johns Hopkins University Hospital
    Baltimore, Maryland
    • Dr Vining reports having no financial or advisory relationships with corporate organizations listed in this activity.

PARTICIPATING FACULTY

    Blaise Bourgeois, MD
    Director, Division of Epilepsy and Neurophysiology
    Children's Hospital
    Boston, Massachusetts
    • Dr Bourgeois reports receiving grant and/or research support from Elan Corporation, Novartis Corporation, Ortho-McNeil Pharmaceutical, Inc, Pfizer, Inc, UCB Pharma, and Wallace Pharmaceuticals; serving as a consultant to Abbot Laboratories, Elan Corporation, GlaxoSmithKline, Novartis Corporation, Ortho-McNeil Pharmaceutical, Inc, Pfizer, Inc, Schwarz Pharma, Shire Pharmaceuticals, and UCB Pharma; and receiving honoraria/serving on the speakers' bureau for Abbot Laboratories, Elan Corporation, Novartis Corporation, Ortho-McNeil Pharmaceutical, Inc, Pfizer, Inc, UCB Pharma, and Wallace Pharmaceuticals.

    Ann M. E. Bye, MBBS, FRACP
    Associate Professor
    School of Women's and Children's Health
    University of New South Wales
    Pediatric Neurologist
    Sydney Children's Hospital
    Sydney, Australia
    • Dr Bye reports having no financial or advisory relationships with corporate organizations listed in this activity.

    Orrin Devinsky, MD
    Professor of Neurology, Neurosurgery, and Psychiatry
    Department of Neurology
    New York University School of Medicine
    New York, New York
    • Dr Devinsky reports serving as a consultant to and on the speaker's bureau for Elan Corporation, GlaxoSmithKline, Novartis Corporation, and UCB Pharma.

    Michael S. Duchowny, MD
    Director, Comprehensive Epilepsy Program
    Department of Neurology
    Miami Children's Hospital
    Miami, Florida
    • Dr Duchowny reports serving as a consultant to Elan Corporation, GlaxoSmithKline, Novartis Corporation, UCB Pharma, and Xcel Pharmaceuticals, Inc.

    Frank Gilliam, MD, MPH
    Director, Adult Epilepsy Center
    Associate Professor
    Department of Neurology
    Washington University School of Medicine
    St Louis, Missouri
    • Dr Gilliam reports receiving grant and/or research support from, serving as a consultant to, and receiving honoraria from Elan Corporation, GlaxoSmithKline, Novartis Corporation, Ortho-McNeil Pharmaceutical, Inc, Pfizer, Inc, and UCB Pharma.

    Paul M. Vespa, MD
    Assistant Professor of Neurosurgery and Neurology
    Director, Neurocritical Care Program
    Department of Neurosurgery
    University of California-Los Angeles
    Los Angeles, California
    • Dr Vespa reports serving as a consultant to the Alsius Corporation.

    Mark Sabaz, BSc
    Research Assistant
    School of Women's and Children's Health
    University of New South Wales
    Sydney, Australia
    • Mr Sabaz reports having no financial or advisory relationships with corporate organizations listed in this activity.

Notice:
In accordance with the ACCME Standards for Commercial Support, the audience is advised that one or more articles in this continuing medical education activity may contain reference(s) to unlabeled or unapproved uses of drugs or devices.

Dr Devinsky - AEDs for psychiatric/behavioral disorders in nonepileptic patients.

All other faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Considering Comorbidities and Quality of Life in Epilepsy Treatment
Peter W. Kaplan, MBBS, FRCP,* and Eileen P. G. Vining, MD

Nearly 1.4 million Americans have epilepsy, with its prevalence now estimated at 5.1 cases per 1000.1 Epilepsy often occurs in childhood,2 and the average incidence of new cases is approximately 5 to 7 cases per 10 000 from birth to age 15 years.3 Significant medical costs are associated with epilepsy management, including costs for frequent visits to the neurologist or the emergency department. The personal and societal costs in terms of reduced quality of life and lost productivity add to the full burden of disease.

Treatment options for epilepsy have expanded over the past decade, but so has awareness of the coexisting conditions that so often complicate treatment. These comorbidities, including depression and brain trauma or, in children, mental retardation, present tremendous challenges to the clinician. One immediate challenge is dealing with the cause-versus-effect conundrum of comorbidities in epilepsy (eg, is the co-existing disorder causing or aggravating the epilepsy or vice versa?). Another exigent task is choosing a treatment course that considers the entire spectrum of patient complaints, reduces the incidence of seizures, and improves overall quality of life. And, still, the clinician must consider that some treatments, such as with an antiepileptic drug (AED), might actually provoke their own set of adverse events or comorbidities.

This issue of Johns Hopkins Advanced Studies in Medicine is devoted entirely to the complexities of epilepsy—comorbidities, quality of life, and treatment effects. To gather recent insights on this important topic, editors of the journal attended presentations and poster sessions at the Annual Meeting of the American Epilepsy Society (AES), December 6-11, 2002, in Seattle, Washington. Summaries of relevant sessions are presented in this special publication.

Dr Orrin Devinsky chaired a special symposium on epilepsy comorbidities and spoke on the common problem of cognitive and behavioral changes in the epilepsy population. The first challenge, according to Dr Devinsky, is recognition. The "mental slowness" or "bit of depression" so often seen in the epilepsy patient, he says, is often interpreted as a "normal reaction" to having epilepsy.4 In the article, Dr Devinsky reviews the pathogenesis of these psychiatric disorders and outlines several pragmatic solutions for improved diagnosis and treatment. He also reminds clinicians of the psychotropic effects of AEDs themselves.

In a related article based on a presentation at the same symposium, Dr Paul M. Vespa reviews the pathophysiologic mechanisms that permit seizures after brain injury and considers the factors that might dictate use of AEDs after brain injury or neurosurgery. Drs Michael S. Duchowny and Blaise Bourgeois focus on the coexisting disorders seen in children with epilepsy, including developmental disorders such as mental retardation and cerebral palsy, as well as the often-subtle behavioral complications related to AED therapy. The authors also address the role of psychostimulant therapy in children with epilepsy and the likelihood of neurobehavioral regression in this young population.

A Special Interest Group at this year's AES annual meeting gathered to discuss the validity and clinical relevance of 2 new health-related quality-of-life instruments for children and adults with epilepsy. Such "behind the scenes" research will be critical in providing clinicians with new tools capable of gauging the full impact of their treatments on patients with epilepsy. As clinicians begin to look beyond seizure frequency to compare AEDs and to define success in patient therapy, the availability of sensitive and well-tested quality-of-life tools will be essential. In this AES session, Dr Frank Gilliam described his recent evaluation of an assessment tool called the Epilepsy Foundation of America Concerns Index. Dr Ann M. E. Bye and Mark Sabaz also reviewed their recent work on development and validation of a new tool for pediatric populations: the Quality of Life in Childhood Epilepsy Questionnaire. There is no question that these are tools of clinical research; however, the information these tools extract from the epilepsy research setting will provide extremely practical guidance to every clinician seeking the best overall outcome.

A range of other platform and poster presentations related to AED therapy are also summarized in this issue and provide further insight into the neuropharmacology and clinical use of these agents. Interestingly, many of these presentations, as well as other AED-related presentations given at the 2002 AES meeting, included evaluations of the impact of drug therapy on nonseizure outcomes, including zonisamide's effect on cognitive decline, lamotrigine's impact on patient satisfaction and quality of life, and topiramate's action on diabetic risk factors such as weight and glycemic control.

It is welcome news that researchers and clinicians are broadening their definition of a desirable outcome in epilepsy therapy. Increasing awareness of disorders coexisting in the epilepsy patient is part of this expanded therapy goal, as well as increased sensitivity to AED impact on nonseizure-related patient functions. As highlighted throughout this issue of Advanced Studies in Medicine, epilepsy comorbidities and quality-of-life issues will influence strategies for epilepsy therapy for years to come.

REFERENCES
1. National Center for Health Statistics. Epilepsy. Available at: www.cdc.gov/nchs/fastats/epilepsy.htm. Accessed February 15, 2003.
2. Kotsopoulos IA, van Merode T, Kessels FG, de Krom MC, Knottnerus JA. Systematic review and meta-analysis of incidence studies of epilepsy and unprovoked seizures. Epilepsia. 2002;43:1402-1409.
3. Cowan LD. The epidemiology of the epilepsies in children. Ment Retard Dev Disabil Res Rev. 2002;8:171-181.
4. Devinsky O, Kanner AM, Ettinger AB. Foreword: therapy for cognitive and behavioral disorders in epilepsy. Epilepsy Behav. 2002;3:S1.

*Associate Professor of Neurology, Johns Hopkins University School of Medicine; Chairman of Neurology, Director of Epilepsy and EEG, Johns Hopkins Bayview Medical Center, Baltimore, Maryland.





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.