Patients with seizure should be referred to epileptologists to make final diagnosis


 Epilepsy is the most common, serious but treatable brain disorder

Patients with seizure should be referred to
epileptologists to make final diagnosis

Detailed history is the cornerstone in making correct diagnosis
while misdiagnosed epilepsy costs Millions-Athanasios Kovanis

Almost 25% cases of epilepsy are preventable while 50% of
these people do not get proper treatment- Prof. M. Wasay

KARACHI: All patients who suffer from seizures should be referred to epileptologists to make correct diagnosis because misdiagnosed epilepsy costs millions. Detailed history is the cornerstone in making correct diagnosis of epilepsy. This was stated by Dr. Athanasios Kovanis President of International Bureau of Epilepsy (IBE) who is also President of the Greek ILAE and IBE chapters. He was making a presentation at a series of symposia held in Pakistan last month. The topic of his presentation was “Diagnosis and Treatment of Epilepsy: Its Global Perspective”. These meetings were very well attended by neurologists, psychiatrists, postgraduates in these disciplines besides some family physicians.

Dr. Athanasios Kovanis

International Bureau of Epilepsy, Dr. Kovanis stated was established in 1961 and at present it has over hundred affiliated organizations in the world. It addresses the social issues of these patients suffering from epilepsy like education, employment, insurance, driving license besides creating public awareness about epilepsy. IBE mission is how to reduce misery of these patients and increase awareness besides improving quality of life of these patients.

Continuing Dr. Kovanis said that there are people who have seizures and they will continue to have seizures despite taking all the anti-epileptic drugs. (AEDs) IBE supports research in epilepsy which is the most common, serious but treatable brain disorder. Almost about 80% of epilepsy patients live in resource poor countries. It is estimated that there are over 700 million people with epilepsy and likely to have fits in their lifetime. About 9,600 new cases of epilepsy are diagnosed every day. As regards prevalence of epilepsy in Europe it is about 2.6-10.9 per thousand while in EMRO Region it is 4.04-12.00 per thousand population. In Pakistan it is estimated that there are about 193 Million people with epilepsy while prevalence of epilepsy in India is about 5.59 per thousand population.

Epilepsy, he further stated, has a multiple etiology. Some of the causative factors are brain infection, head trauma, tumour, and cerebrovascular disorders. There is variation in different regions. In Pakistan, Dr. Kovanis said, driving is not safe.  With proper treatment almost 70% of people with epilepsy are seizure free in developed world, some have less seizures and enjoy improved quality of life. One of the systematic reviews has pointed out that the treatment gap was almost 56%. Lack of awareness and educaiotn are termed as the major reasons for this treatment gap. Other reasons include poverty, lack of resources, drift to private sector, and lack of professional health workers, accessibility and affordability of anti-epilepsy drugs, non-availability of AEDs. Not only that the latest drugs are not available in many countries but are also very expensive. Lack of resources and fast growth of population have also contributed to the treatment gap. For diagnosis of epilepsy some of the most useful investigations include CT, MRI, and EEG. Only about 56% of patients in developing countries are diagnosed and they also get inappropriate treatment. Phenytoin, Valporate and Carbamazepine etc., are much more expensive in developing countries.

Prof. Shaukat Ali along with Mr. Jamshed Ahmad COO PharmEvo presenting a
mementoe to Dr. Athanasios Kovanis at the Symposia on Diagnosis and 
Management of Epilepsy at Karachi.

Dr.  Athanasios Kovanis was of the view that correct diagnosis and treatment of epilepsy was very important. One has to make sure that it is an epileptic fit, seizure and not a non-epileptic fit. The healthcare professionals must recognize the non-epileptic seizures. One should remember that epilepsy seizures are usually self-limiting but many fits, seizures look like epileptic seizures like staring, altered responsiveness, loss of conscious, collapse, limb movements. In these patients one does not need to do anything further in these psychogenic features. Refer all patients with seizures to epileptologists to make final diagnosis. Always make sure that it is epileptic seizure, what is the cause, what type of seizures and what is the epilepsy syndrome. Diagnosis is based on history, EEG using correct methodology and is also depends on the experience of the doctor to analyze it. One should collect all information while making diagnosis. Misdiagnosed epilepsy will result in waste of financial resources. Make sure that the EEG report is written and read by competent neurologists. Treatment failure could lead to long term consequences. It could also be due to wrong diagnosis and we should not be playing with the quality of life of these children.

Continuing Dr. Athanasios Kovanis said that in the recent years there have been tremendous advances in Neuro-imaging and genetics. It needs expertize to diagnosis epilepsy in in different stages i.e. neonatal period, during infancy and childhood. Talking about classification of seizures he mentioned   focal, generalized, generalized focal and unknown. Some seizures are very resistant to anti-epileptic drugs. In some patients one might have to use rectal diazepam to stop seizures. He supplemented his presentation on various types of seizures with Video presentations of various seizures and syndromes. Benign focal seizures are self-limiting and it is known as benign childhood epilepsy. He also talked about some practical classification of epilepsy. These children do suffer from some educational problems.  Such Paediatric seizures and epilepsies are different.

Myoclonic syndrome is brief, sudden, results in muscle contractions of the whole body or some body parts. He then showed a video of myoclonic epilepsy in infancy and childhood. Juvenile myoclonic epilepsy is a complex genetic. Some patients have seizures due to photo sensitivity. Treatment of first seizure has an impact on recurrent risk over a short period but not over a long term period. While managing epilepsy, Dr. Athanasios Kovanis advised to use correct drugs, avoid un-necessary drugs and investigations. Non responders should have surgical evaluation. It is extremely important to involve the patient and family in treatment decisions and in every decision making. Listen to their feelings and emotions of the family. Special groups need special attention. Use of two sodium channel blockers have no advantage. Side effects vary with certain drugs. He concluded his presentation by emphasizing that avoid un-necessary therapy. VPA is the first choice except in females with child bearing age. Almost 47% of epilepsy patients respond to monotherapy in general.  Some drugs have a response rate of 85-90% if one separates the seizures. One of the studies from Pakistan has reported that about forty eight thousand epilepsy patients need assessment for epilepsy surgery.

Earlier Prof.M. Wasay Prof. of Neurology at Aga Khan University in his presentation on Epilepsy: Burden, Outcome and future interventions pointed out that global burden of epilepsy was more than TB, HIV, AIDs and it was a highly disabling disease. There are about 65 million people with epilepsy in the world, about two million were in Pakistan and it was most common in children with a prevalence of 14.6 per thousand population. Epilepsy accounts for almost over fifty thousand deaths every year and its prevalence was more in people less than thirty years of age. About twenty five Anti Epilepsy drugs are available including the First line and the new generation drugs. Cost of treatment varies from Rupees Fifty to ten thousand per month. Facilities for epilepsy surgery are available at one center in Pakistan. Diagnosis is mostly clinical and it is based on history of the patient and history from the family. One needs to rule out cause of seizures by doing certain blood tests, and MRI.  There are numerous myths about epilepsy and it is extremely important to create awareness and educate the people about this disease. Some people think it is a psychiatric disorder and not treatable which was wrong. Almost 70% cases of epilepsy are idiopathic with no known etiology while the rest 30% are due to traumatic brain injury, infection, stroke, tumour while 5% can be due to some genetic deficiency. Almost 25% cases of epilepsy are preventable but 50% of these people do not get proper treatment.

Dr. Athanasios Kovanis President International Bureau of Epilepsy photographed along with the
speakers and panelists after the symposia on Diagnosis and Management of Epilepsy at Karachi.
Picture shows Dr.Abdul Malik, Prof. Shaukat Ali, Dr. Athanasios Kovanis, Mr. Jamshed Ahmad,
Prof. M. Wasay, Dr. Fauzia, Prof. Iqbal Afridi and Dr. Waseem Akhtar.

Continuing Prof. Wasay said that almost 75% of these people with epilepsy can be controlled with one drug. Major problem is lack of awareness in public as well as in healthcare professionals. Other important issues are affordability of drugs particularly in rural areas. There are about two hundred neurologists in Pakistan which means there is one qualified neurologist for one million population which was not enough. There are about one thousand psychiatrists who also treat epilepsy. We need to educate the family physicians in diagnosis and treatment of epilepsy. People with epilepsy Prof. Wasay said can do everything. Almost 90% of women who suffer from epilepsy are not treated and it is a stigma. Female with epilepsy can have successful pregnancy and have children. However, while treating these female one has to take into account the risks of birth defects and breast feeding. He further disclosed that Pakistan Society of Neurology was working on a Patient Support Programme. We have so far trained over one thousand family physicians in twenty cities. We need to have a multidisciplinary organization to support and help these patients and we are currently working on this.

Dr. Fouzia Siddiqui also from Aga Khan University discussed the Guidelines for treatment of Epilepsy and laid emphasis on having Pakistan specific Guidelines. These guidelines prepared by the Epilepsy Foundation of Pakistan gives details of seizure types and which drug should be used in which seizures. Monotherapy is preferable. Education of the patient is important. One needs to establish the correct diagnosis, look into the psychological issues, life style and non-medical treatments. She also briefly referred to medical treatment and evaluation for surgery.

The meeting at Karachi held on September 26th was chaired by Prof. Shaukat Ali former Prof. of Neurology at Jinnah Postgraduate Medical Center while Dr. Mughees Sherani was the co-chairman.  Panel of experts included Prf.  Iqbal Afridi from JPMC and Dr. Waseem Akhtar consultant neurologist at Abbasi Shaheed Hospital.

Responding to questions during the discussion Dr. Athanasios Kovanis said that there was no specific tool to measure the burden and quality of life of the epilepsy patients. We need to do networking in the region to collaborate in further research in epilepsy. New drugs offer better quality of life but not better outcome. That is one of the reasons that the Pharma industry has stopped further research to bring new drugs which was bad. Quality of life measurement could be different in UK, USA, Japan and other countries. For a country like Pakistan, you should see how many children with epilepsy go to schools, are on job working in various organizations. Make sure that the girls should get married. These things need to be tailored to Pakistan.  Which patients at what age need to be assed for surgery also came under discussion. In order to discover something to be operational, it depends how well you have evaluated the patient. In some resistant epilepsy cases, Benzodiazepine is used and they may respond but I am against its use as it may lead to addiction, hence it should be avoided. Benzodiazepine can be used in status epilepticus but make sure to use the correct dose.

In his concluding remarks Prof. Shaukat Ali thanked the guest speaker for his informative talk highlighting important issues regarding epilepsy, diagnosis, treatment with a global perspective. In Pakistan Prof. Hasan Aziz had done an epidemiology study about epilepsy many years ago. Pakistan Society of Neurology has been doing a commendable job to remove stigma, create awareness and improve care of epilepsy in Pakistan. Over the years we have been able to improve the situation but still a lot more needs to be done.

The meeting was sponsored by PharmEvo Pharmaceuticals. Dr. Masood Jawaid Director Medical Affairs PharmEvo in his brief address highlighted the academic activities of the company which are directed as professional capacity building of the healthcare professionals’. The meeting was conducted by Dr. Abdul Malik while Mr. Jamshed Ahmad Chief Operating Officer PharmEvo thanked the speakers, panelists and the participants.