Should My Child Switch Epilepsy Medications Based on EEG Results?

Please inquire about epilepsy medications?

My daughter is 3 and a half years old and has been taking Lamotrigine for epilepsy for six months.
Recently, we conducted a follow-up EEG after six months of medication and found that her entire brain starts to discharge as soon as she falls asleep.
The doctor suggested switching to Valproate, as it is effective for generalized brain discharges, but mentioned that it is also acceptable to continue with Lamotrigine to see how it goes.
My daughter exhibits clinical symptoms of awareness (she will scream when she feels uncomfortable or scared) and has focal seizures (eye rolling and hand clenching).
In the past six months, she has only had two seizures (in total, since her diagnosis and starting medication, she has had four seizures, which are considered mild).
Lamotrigine is still appropriate for her condition.
However, the first prescription was given by a different doctor at another hospital, and there was not much explanation provided at that time.
I was so frightened by the diagnosis that I forgot to ask relevant questions, so I am unclear about the initial considerations for the medication.
Should we base the decision to switch medications on the EEG results, or should we continue with the current medication based on her seizure activity? Thank you for your response.
(Since there are no pediatric neurologists at the clinic, I had to consult you.
I apologize for any inconvenience and thank you once again!)

Yáo wěi bù dìng de mā, 30~39 year old female. Ask Date: 2007/10/16

Dr. Pei Rensheng reply Pediatrics

Hello! Although my specialty is pediatric gastroenterology and pulmonology, I will do my best to find answers for you.
I hope this information is helpful!
A.
Tegretol (Carbamazepine)
Indications: Generalized tonic-clonic seizures, complex partial seizures, mixed seizures, epilepsy-related personality disorders, and trigeminal neuralgia.

Side effects: Dizziness, headache, ataxia, drowsiness, fatigue, diplopia, nausea, vomiting, loss of appetite, slurred speech, dry mouth, skin allergies, leukopenia, etc.

Precautions:
1.
The medication can be split but should not be crushed.

2.
Special caution is advised when operating machinery or driving after taking the medication.

3.
Carbamazepine has been associated with agranulocytosis and aplastic anemia, but due to the low incidence of these abnormalities, it is difficult to accurately estimate the risk.

4.
During treatment with Carbamazepine, occasional or persistent decreases in platelet or white blood cell counts may occur.
These symptoms are usually temporary.

5.
Special caution should be exercised when using Carbamazepine for mixed seizures (including absence seizures, typical or atypical).
In such cases, Carbamazepine may worsen the seizure condition.
If seizures worsen, Carbamazepine should be discontinued.

6.
Regular liver function tests should be conducted during Carbamazepine treatment, especially for patients with a history of liver disease and elderly patients.

B.
Depakine (Valproic Acid)
Indications: Generalized and focal epilepsy, seizures in children or febrile seizures, and behavioral disorders associated with epilepsy.

Action: Treats generalized tonic-clonic seizures, absence seizures, mixed-type temporal lobe epilepsy, and other epilepsy-related behavioral disorders.

Side effects: Gastrointestinal discomfort (nausea, vomiting, loss of appetite, etc.), sedation, agitation, dizziness, depression, ataxia, liver function abnormalities, tremors, hair loss, etc.

Precautions:
1.
This medication may affect driving response and ability.

2.
Especially when combined with alcohol or during the initial treatment phase, it can impair driving and machinery operation abilities.
Alcohol should be avoided during treatment.

3.
Regular monitoring of liver, pancreatic, renal function, coagulation status, and Valproic acid blood levels is required during treatment.

4.
If any of the following symptoms or side effects occur (especially those affecting the liver or pancreas: unexplained abdominal pain, vomiting, loss of appetite, high fever, fatigue, weakness, disorientation, lack of drive, seizures, numbness, transient rash, liver enlargement, jaundice, ascites, respiratory distress, central nervous system damage, coagulation disorders), inform your physician immediately.

5.
Inform your physician before any surgical or dental procedures that you are taking Valproic acid.

6.
Do not crush the medication.

Contraindications:
1.
Allergy to Valproic acid, liver or pancreatic dysfunction.

2.
Use with caution in the following patients: (1) history of pancreatic disease or bone marrow damage; (2) increased bleeding tendency; (3) renal dysfunction; (4) congenital enzyme deficiencies; (5) severe seizures; (6) children with developmental delays; (7) brain injury; (8) children under 2 years old (due to increased risk of liver damage); (9) breastfeeding is not recommended during treatment.

Max Dose: 60 mg/kg/day
C.
Dr.
Zhang Zhaoliang is a pediatric neurologist at Taoyuan Hospital, and he has special outpatient clinics every other Tuesday afternoon where you can register on-site.
You may bring your EEG report to discuss with him.
Please consider this! Wishing you health and happiness!
Respectfully,
Pei Rensheng, Director of Pediatrics, Taoyuan Hospital

Reply Date: 2007/10/16

More Info

When it comes to managing epilepsy in children, especially in your daughter's case, the decision to switch medications based on EEG results is a nuanced one that should consider multiple factors, including clinical symptoms, EEG findings, and the overall response to the current medication.

Your daughter has been on Tegretol (Carbamazepine) for six months, and the recent EEG indicated generalized spike-and-wave activity upon sleep, which suggests a potential for generalized epilepsy. The doctor has suggested that switching to Depakine (Valproic acid), which is often used for generalized seizures, could be beneficial. However, it is also noted that her clinical symptoms have been relatively mild, with only two seizures in the past six months and a good level of awareness during episodes.

Factors to Consider:
1. Clinical Symptoms vs. EEG Findings:
- The fact that your daughter has only had a few seizures and maintains awareness during them is a positive sign. In many cases, the clinical presentation can be more telling than EEG results alone. If the seizures are infrequent and manageable, it may be reasonable to continue with the current medication while monitoring her condition closely.

2. Medication Efficacy and Side Effects:
- Tegretol is effective for certain types of seizures, but it can sometimes exacerbate other seizure types. If your daughter’s seizures are well-controlled and she is tolerating the medication without significant side effects, it may be worth continuing with Tegretol. On the other hand, if there are concerns about the potential for her seizures to evolve or worsen, switching to Depakine might be warranted.

3. Potential for Medication Adjustment:
- If you decide to stay with Tegretol, it’s crucial to have regular follow-ups and EEGs to monitor her brain activity and seizure frequency. If her condition changes or if she experiences more frequent seizures, then a reevaluation of her treatment plan would be necessary.

4. Consultation with a Pediatric Neurologist:
- Since you mentioned that there are no pediatric neurologists available at your current facility, it may be beneficial to seek a second opinion or consultation with a specialist who has experience in pediatric epilepsy. They can provide more tailored advice based on the latest research and treatment protocols.

5. Long-term Management:
- Epilepsy management is often a long-term process that may require adjustments in medication as the child grows and their condition evolves. It’s essential to maintain open communication with your healthcare provider about any changes in your daughter’s behavior, seizure frequency, or side effects from the medication.

Conclusion:
In summary, the decision to switch medications should not be based solely on EEG results but should also consider your daughter's clinical symptoms, her response to the current medication, and the potential risks and benefits of switching to a new medication. If her seizures remain infrequent and manageable, continuing with Tegretol while monitoring her condition may be appropriate. However, if there are concerns about the nature of her seizures or if they increase in frequency, discussing a switch to Depakine with a specialist would be advisable. Always ensure that any changes in medication are made under the guidance of a qualified healthcare professional.

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