Nonpharmacologic Therapy

Several nonpharmacologic treatments for epilepsy are available. For some patients, surgery is the treatment approach with the greatest probability of eliminating seizures. The most common surgical approach for epilepsy is temporal lobectomy. When the seizure focus can be localized and it is in a region of the brain that is not too close to critical areas, such as those responsible for speech or muscle control, surgical removal of the focus can result in 80% to 90% of patients becoming seizure free. According to a National Institutes of Health Consensus Conference, three criteria

should be met for patients to be candidates for surgery. These criteria are (a) a definite diagnosis of epilepsy; (b) failure of adequate drug therapies; and (c) definition of the electroclinical syndrome (i.e., localization of the seizure focus in the brain). Other surgical procedures that are less likely to make a patient seizure free include corpus callosotomy and extratemporal lesion removal.

Vagal nerve stimulation is another nonpharmacologic approach to treating all types 24

of seizures. In this treatment, a unit that generates an intermittent electrical current is placed under the skin in the chest. A wire is tunneled under the skin to the left vagus nerve in the neck. The unit generates a small electrical current every 5 minutes that stimulates the vagus nerve. Additional stimulations can be initiated by the patient swiping a magnet over the device located in the chest. This treatment approach is essentially equivalent to starting a new medication with regard to efficacy, but the precise mechanism for its effect has not been elucidated. Approximately 25% to 50% of patients who have a vagal nerve stimulator placed will experience at least a 50% reduction in seizure frequency. However, fewer than 10% become seizure free. Adverse effects include hoarseness, swallowing difficulties, tingling or vibration in the neck, infection or bleeding due to surgery, and, rarely, laryngeal spasms. Vagal nerve stimulation is usually reserved for patients who do not respond to several drugs and are not surgical candidates.

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One of the oldest nonpharmacologic treatments is the ketogenic diet. Modern use of the diet was started in the 1920s. This diet produces a keto-acidotic state through the elimination of nearly all carbohydrates. To initiate the diet, patients undergo 24 to 48 hours of fasting until ketones are detected in the urine. The diet consisting of dietary fats (e.g., butter, heavy cream, fatty meats) and protein with no added sugar is started. Daily urinalysis for ketones is performed to ensure the patient remains in ketosis. Any inadvertent consumption of sugar results in the diet needing to be reinitiated. Pharmacists have an important role in maintaining the diet, by determining the sugar or carbohydrate content of medications the patient is taking. This diet is typically used only in children with difficult to control seizures. In certain patients the diet can be extremely effective, resulting in complete seizure control and reduction of AEDs. However, it is hard to maintain a ketotic state, and palatability of the diet is

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FIGURE 30-2. Treatment algorithm for management of seizure disorders.

a concern. Additionally, there are concerns about growth retardation in children and hypercholesterolemia with prolonged use of the diet.

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