Epilepsy is one of the most common neurological diseases – there are about 50 million of people suffering from this still incurable disease. Exact causes of abnormal neuronal activity in brain are still uncertain, therefore there is only symptomatic treatment available. However, therapeutic issues are not the only problem. Coexistence of mental disorders, lack of basic knowledge about epilepsy in society, stigma – these are only few point in discussions about epilepsy. According to the interview with John Pellock, president of American Epilepsy Society, let’s have a look at new directions in epileptic care (1).
Two main pathomechanisms of epilepsy are brain damage and neurotransmitters and ion channels disorders. Mutations of different kinds of ion channels lead to various types of epilepsy and for that reason many drugs used in epilepsy treatment are targeted to these channels. Lamotrigine, phenytoin and carbamazepine are the inhibitors of voltage-gated Na channel, whereas retigabine is connected with voltage gated K channel (2). This knowledge leads to the conclusion that we should chose antiepileptic treatment depending on pathomechanism of epilepsy, because improperly chosen drugs may even aggravate the symptoms. However, we have to be aware that channelopathies are responsible not only for neurological disorders, but also cardiac manifestations – for example Brugad’s syndrome and long QT syndrome. It is extremely important in the context of SUDEP (sudden unexpected death in epilepsy) phenomenon. We are still unable to answer the question, if there is an accurate connection between ion channels disorders in epilepsy and cardiac dysfunction. This issue have some clinical implications – the risk of sudden death might be higher depending on epilepsy type. So, according to this information, should physicians consider doing an ECG each person with epilepsy? And, should cardiologists recommend EEG for people with long QT syndrome? More researches are required to make any conclusions.
Not only cardiac disorders may be a problem in epilepsy. Many studies revealed that people with epilepsy more often suffer from depression – data say it is 20 to 50 per cent of patients (3). The connection between depression and temporal lobe epilepsy is well known, however its relationship with various types of epilepsy is unclear. It is significant to reveal, whether both disorders have the same primary cause (e.g genetic, biochemical) or is depression only a result of recurrent seizures. If so, does it have organic background, connected with local brain damage after neuronal hyperactivity, or is it a psychological effect of having epilepsy, or maybe there is totally different pathomechanism. Interestingly, antiepileptic drugs are popular in modern psychiatry – carbamazepine and valproate are used as mood stabilizers in bipolar disorder, lamotrigine – in depression. It may lead to the hypothesis that epilepsy and psychiatric disorders have similar causes. However, without further studies it is impossible to confirm it.
The next issue concerns children misdiagnosing. Children quite often have some educational problems at school. It is significant to distinguish attentional difficulties from seizures recurrence, which is not always as simple as it seems. Right diagnosis ensure appropriate treatment. Therefore we have to be aware that this kind of difficulties not always appears as a result of epilepsy and we should consider other options before therapy beginning.
Still, the scientists have not found ideal treatment for epilepsy, which could remove the basic cause. So far, we are able to offer our patients different kinds of therapy: surgery, vagal stimulation, drugs. The big problem with invasive methods are difficulties in classifying patients to them. Access to alternative therapies should be more common. Now, the most popular treatment are drugs. Group of antiepileptic drugs in short time may include two new medications. Perampanel is highly selective non competitive AMPA type glutamate receptor antagonist and can be useful in partial-onset seizures4, whereas retigabine is a first K-channel antiepileptic drug, which reduces hyperactivity of the neurons through the stabilization of the K-channels in an open position (5). They can be a hope for people, who do not react to the previous treatment.
Sadly, some issues have not disappeared since decades. There is not enough neurologists with subspeciality: epileptologist, who would be able to take professional care of patients with epilepsy. What is more, still, in our society there is a stigma. Epilepsy is not treated as a usual disease. There are many myths about it. People are afraid of word “epilepsy”, they prefer “seizure disorder”, because it does not cause so many negative connotations. Therefore so important is education about this disease and refuting stereotypes.
As we can see, there is still so much to do epilepsy care. We have to find exact causes, search for the best individual treatment, built modern patient care system and prepare educational programs, which aim will be to supply knowledge about this disease, both for patients and the rest of society. It is the only way to ensure people with epilepsy normal life.
1.New Directions In Epilepsy Care. An interview with AES president Dr. John Pellock, http://www.medscape.com/viewarticle/745266, (15.07.2011)
2.Armijo, J. A.; Shushtarian, M.; Valdizan, E. M.; Cuadrado, A.; Cuevas, I. d.l.; Adin, J., Ion Channels In Epilepsy, Current Pharmaceutical Design, Volume 11, Number 15, June 2005 , pp. 1975-2003(29)
3.Depression in Epilepsy Is Much More Than a Reactive Process, Attarian H, Vahle V, Carter J, Hykes E, Gilliam F, Epilepsy Behav 2003;4:298–301
4.Kevin Grogan, Eisai files epilepsy treatment perampanel, http://www.pharmatimes.com/Article/11-06-29/Eisai_files_epilepsy_treatment_perampanel.aspx (15.07.2011)