Epilepsy Awareness Month

What is epilepsy?

Epilepsy is a disorder that is best described as disturbed electrical activity in the brain. This activity usually appears as a seizure. Seizures can also be caused by other conditions or by seizure-inducing activities. To be considered to have epilepsy a person has to have 2 or more seizures that are not caused by illness or any other provoking event. Seizures from epilepsy can vary in their appearance, severity, and cause. Although seizures are the main symptom of the disease, patients’ lives can be affected in many other ways by epilepsy.

How many people are affected by epilepsy?

There are 120 per 100,000 people in the United States that go to the emergency room or doctor because of a seizure, and approximately 125,000 new cases of epilepsy occur every year. It estimated that about 2 million people in the United States have epilepsy, and 50 million people throughout the world have epilepsy as estimated by the World Health Organization (WHO). Epilepsy occurs more frequently in younger children less than 2 years old and adults older than 65 years old. Epilepsy has an estimated annual cost of $15.5 billion in medical costs and lost or reduced earnings and productivity.

What are the types of epilepsy?

Epilepsy can be classified into 2 different groups by seizure type or as an epileptic syndrome. The seizures type is generally determined by an electrical study of the brain (an electroencephalogram or EEG) and the behavior of a person during and after a seizure. There are 2 major types of seizures, generalized seizures and partial seizures (see Table below).

Table. Types of seizures associated with epilepsy.

Seizure types		Description
Generalized seizures	Tonic, clonic, tonic-clonic, atonic, myoclonic, absence	Involve a large, widespread part of the brain
Partial seizures	Simple (no loss of consciousness) or complex (loss of consciousness)	Affect a smaller area of the brain and are more localized

Epileptic syndromes differ from epilepsy in that they are associated with more signs and symptoms than just seizures, including slow mental development. Epileptic syndromes are defined by a cluster of factors including seizure types, age when seizures begin, EEG findings, brain structure, family history of epilepsy, genetic disorder, and prognosis or future outlook. The epilepsy syndromes can be classified into 4 categories. These include familial, symptomatic, idiopathic, and reflex. Some syndromes and seizure types may not fall under any of the categories and be classified as unknown.

What are the signs and symptoms of epilepsy?

The symptoms a person experiences will depend largely on the type of seizure they have. They can present very noticeably such as a generalized tonic-clonic seizure where the patient will fall to the ground with muscle jerking or can be hardly noticeable with an absence seizure where a person just seems to be staring off into space for a moment. Between seizures there are usually no outright signs of epilepsy. Patients are unable to predict when another seizure will occur.

What can cause epilepsy?

Epilepsy may develop early in life or at any point when an event occurs that alters the connection between the nerve cells of the brain. Conditions or events that can cause this include:

• oxygen deprivation (eg, during childbirth)
• brain infections (meningitis, encephalitis)
• traumatic head or brain injuries
• stroke
• brain tumors
• other neurological diseases (eg, Huntington's disease, Alzheimer's disease)

In some cases epilepsy can be inherited as part of certain syndromes, but in most cases of epilepsy the cause is unknown.

Can epilepsy be prevented?

Depending on the cause of epilepsy there are some actions that can be taken to prevent it. Some of these include:

• prenatal care to avoid complications associated with pregnancy
• immunizations to lessen the likelihood of certain infections that can be linked with epilepsy
• reduce your risk of falls and motor vehicle accidents that are often causes of epilepsy
• reduce your risk for stroke by treating obesity, physical inactivity, diabetes, high blood pressure, and high cholesterol, and quit smoking

How is epilepsy diagnosed?

Epilepsy should be diagnosed by a specialist with training and expertise in epilepsy. A person would be evaluated for epilepsy when they have had more than one seizure of an unknown cause. The official diagnosis of epilepsy is a combination of 2 more seizures not caused by illness. There are 3 major areas of testing that will be done to help diagnosis epilepsy.

• Laboratory or blood tests:  none specifically diagnosis epilepsy but will be used to help rule out other conditions that may cause a seizure
• An EEG can be used to show abnormal brain activity
• Magnetic resonance imaging (MRI): will be used to look for any abnormalities in the brain to help determine a cause of seizures or epilepsy

Finally other conditions and precipitating factors need to be ruled out to diagnose epilepsy. These include seizures from alcohol or drugs, chemically-induced seizures, migraines, panic attacks, transient ischemic attacks, and several others.

After a patient is diagnosed with epilepsy doctors will want to determine the seizure type to help guide treatment decisions. There are multiple factors that go into diagnosing the seizure type. These include the EEG findings, duration of seizure, patient’s behavior during and after the seizure, and whether the patient loses consciousness during the seizure.

How is epilepsy treated?

Once a person’s diagnosis of epilepsy has been confirmed and their seizure type determined their treatment will be begin. Epilepsy treatment can include a variety of options.

• Antiseizure medications are the backbone of treatment for epilepsy. There are several available and choosing which one will be used is based on a variety of factors. These include seizure type, other health condition and medications, patient age, and side effects of the medication. Usually 50% to 70% of patients will be controlled with one antiseizure medication. For 30% to 35% of patients, medication will not be able to control their seizures and they will have to seek other treatment options.²
• Surgery is an option for epilepsy that cannot be controlled with medication alone. This is especially true when the abnormal electrical activity that causes the seizure mostly starts from the same portion of the brain. In some cases, surgeons can remove this area, stopping seizure activity.
• Vagus nerve stimulators are sometimes used if surgery cannot be done. This is an electrical device that is implanted into the head and intermittently releases an electrical shock. This is reported to reduce seizure frequency in epilepsy.
• A ketogenic diet is reported to be associated with seizure reduction. This diet is high in fat and low in carbohydrate. The diet typically has a 3:1 ratio of fats to carbohydrates. It is said to be most effective in generalized and partial epilepsy.

Finding the right treatment for epilepsy takes careful review of a patient’s symptoms and side effects of therapy, working closely with their doctor.

How can I prevent complications if I already have epilepsy?

People with epilepsy should avoid factors or activities that may precipitate or cause a seizure, such as sleep deprivation, fever, alcohol intake, and certain light stimulation. Families, caregivers, and patients should also be educated about road and driving safety, first aid, and prevention of injury at home, work, and school.

Where can I find more information at?

There are several resources online where you can find more information about epilepsy. You can also talk to your doctor or pharmacist for more information.

·      Epilepsy Foundation

http://www.epilepsyfoundation.org/

·      Centers for Disease Prevention and Control

http://www.cdc.gov/Features/EpilepsyAwareness/

·      Managing Epilepsy Well Network

http://web1.sph.emory.edu/ManagingEpilepsyWell/

Written by:    Katy Skowronski

Doctor of Pharmacy Candidate

College of Pharmacy, University of Illinois at Chicago

UIC Pharmacy

August 2013

Diabetes Eye Disease Awareness Month

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What is diabetic retinopathy?

Diabetic retinopathy is one of several eye diseases that can affect individuals with diabetes. It most commonly occurs when an individual’s diabetes is uncontrolled. This disease can cause vision problems and can lead to blindness. This happens when blood vessels on the retina (see Figure below), which is the tissue lining the inner eye, are damaged. Some individuals may have blood vessels that swell and leak, others may have small blood clots or occlusions in their blood vessels, and others may have new blood vessels forming on their retina.

There are 2 other eye diseases that may also be common in individuals with diabetes. One is cataracts, which is clouding of the lens of the eye. Another is glaucoma, which is increased pressure inside of the eye. These conditions can also lead to vision loss and even blindness.

The Figure above shows the anatomy of the eye. The retina is the tissue that lines the inner part of the eye. It contains many blood vessels, which allow blood to carry oxygen to the eye. It also contains rods and cones, which are responsible for our vision. The macula is an area near the back of the eye that is responsible for our sharp, central vision. Parts of the retina that do not contain the macula help us see peripherally, or to the sides. The fluid inside the eye is known as vitreous humor or gel.

How many people are affected by this condition?

·      Most individuals diagnosed with type 1 diabetes as children will develop diabetic retinopathy when they are 20 to 40 years old.

·      Approximately 20% of individuals who are newly diagnosed as having type 2 diabetes already have diabetic retinopathy. These individuals often have had diabetes for years, however, due to lack of symptoms, they have gone undiagnosed. Unfortunately, by the time they are diagnosed, the damage to the eye may have already occurred.

·      Within 20 years of being diagnosed with type 2 diabetes, about 60% of individuals will develop diabetic retinopathy.

 

What types of diabetic retinopathy are there?

·      Nonproliferative diabetic retinopathy (NPDR) accounts for approximately 80% to 95% of diabetic retinopathies. Nonproliferative means that no new blood vessels are forming on the retina. However, blood vessels already present are often enlarged and become leaky. This can lead to fluid, blood, and debris from cells leaking into the eye. This disease can progress and cause more problems. Advanced nonproliferative (maculopathy) often presents as swelling of the macula (called macular edema) and lesions, or areas of damage, on the retina. The macula is an area on the retina that is responsible for much of our vision, and macular edema is the often the cause of blindness in patients with diabetes. Within 5 years, approximately 5% to 20% of individuals with macular edema will be considered legally blind.

·      Proliferative diabetic retinopathy (PDR) accounts for approximately 5% to 10% of diabetic retinopathy. This involves neovascularization, or new growth of blood vessels, on the surface of the retina. Within 5 years 50% of these individuals are diagnosed as legally blind.

What are the common signs and symptoms that are associated with diabetic retinopathy?

Most individuals do not have any signs or symptoms of diabetic retinopathy until it is too late to correct the vision loss that may have already occurred. Diagnosing the disease early, through periodic eye exams, can help to slow the progression of the disease. It is important to identify changes to the eye early in order to take steps to stop any further damage. Some of the symptoms that may be experienced include:

-       Blurry vision

-       Dark or floating spots

-       Trouble seeing things that are at the center of your focus when reading or driving

-       Trouble telling colors apart

What are the common causes or risk factors for diabetic retinopathy?

Risk factors include:

-       Presence of type 1 diabetes

^-       Having diabetes for a long time: The longer someone has diabetes, the more likely they are to get diabetic retinopathy, and it has been shown that the risk begins to increase after an individual has had type 2 diabetes for more than 4 years.

-     High A1C levels: A1C levels above the American Diabetes Association goal of  <7% indicate uncontrolled diabetes over a 3-month period. The highest risk is with an A1C >12%, but the risk is increased with all levels above goal. Diabetic retinopathy is rare in individuals with an A1C <7 span="">

-       High blood pressure: Having high blood pressure that is uncontrolled, as determined by your doctor, can lead to further damage to the blood vessels of the eye.

-       Pregnancy: Diabetic retinopathy can worsen in approximately 16% to 85% of pregnant women with preexisting diabetes.

      

What are the current recommendations for screening for diabetic retinopathy?

• Adults and children aged 10 years or older with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of diabetes.

A comprehensive eye exam should include:

-       tonometry, which measures pressure in the eye

-       visual field test, which measure your peripheral or side vision

-       visual acuity test, which tests how well you can see at a variety of distances.      

• Shortly after being diagnosed with type 2 diabetes, individuals should have a dilated and comprehensive eye examination.
• Individuals with either type 1 or type 2 diabetes should have annual eye exams. If one or more eye exams are found to be normal, the ophthalmologist or optometrist may allow less frequent exams (every 2 to 3 years). If it is found that retinopathy is getting worse, more frequent examinations will be required.
• Women with preexisting diabetes who are planning a pregnancy or who have become pregnant should have a comprehensive eye examination. It is also important that those individuals are counseled on the possible development and/or worsening of diabetic retinopathy during pregnancy. Eye examinations should occur in the first trimester with close follow-up throughout pregnancy and for 1-year postpartum.

Why is early diagnosis important?

As stated above, most individuals do not have any signs or symptoms of retinopathy until it is too late to correct the damage that has been done. Diabetic retinopathy is the most common cause of new blindness in adults between the ages of 20 and 74 years in the United States.

What tests are done for the diagnosis of diabetic retinopathy?

^·        Dilated eye exam: The ophthalmologist or optometrist gives the individual eye drops to make their pupils dilate or open. This makes it easier to see the inside of the eye and back to the retina.

• Digital retinal imaging: For this test, pictures of the eye are taken with a special camera and the pictures are looked at by the ophthalmologist or optometrist. They look for anything that is abnormal on the retina, such as spots or new blood vessels.
• If either the dilated eye exam or the digital retinal imaging test shows a problem, the  doctor might suggest other tests also.
• Stereoscopic color fundus photographs are pictures of the interior of the eye that can help detect anything that is not normal.
• Fundus photographs can detect eye damage and should be performed along with the dilated eye exam and digital retinal screening at least at the first appointment.
• Fluorescein angiography: Fundus photographs may miss macular edema or proliferative diabetic retinopathy, so another test called fluorescein angiography is performed. A fluorescein dye is injected into a vein and photographs are taken that track how the dye travels in the retina. It can detect if the blood vessels are blocked or if they are leaking.

What treatments are available for diabetic retinopathy?

• Controlling risk factors such as high blood pressure, high cholesterol, and uncontrolled diabetes are important in the prevention of diabetic retinopathy as well as in the management of the disease.
• Laser photocoagulation is a laser surgery that is used to stop blood vessels in the retina from leaking or growing. 

-       Focal laser photocoagulation: Used in individuals with macular edema, focuses         on a specific area.

-       Panretinal photocoagulation: Used mostly in individuals with proliferative diabetic retinopathy, and sometimes for individuals with severe nonproliferative diabetic retinopathy, includes most parts of the retina.

^-               Focal photocoagulation is preferred as first-line treatment to minimize worsening of macular edema that may occur after panretinal photocoagulation.

• A vitrectomy is a surgery that is used to remove blood from the fluid in the eye (the vitreous humor). This is done when blood vessels in the retina leak into the fluid. It is most helpful in proliferative diabetic retinopathy.
• Anti-vascular endothelial growth factors (VEGF) are used for macular edema as an additional option. What these medications do is stop new blood vessels from forming. Anti-VEGF medications include bevacizumab, ranibizumab, and pagaptanib.
• Macular edema that is not improved by other means may be treated with intravitreal steroid injections, which are injections directly into the fluid in the eye, to improve visual outcomes. A few of the steroids used are triamcinolone, fluocinolone, and dexamethasone.
• It is important to discuss all treatment options with your doctor to determine which is best for you.

What can individuals do to prevent this condition?

It is important to discuss any prevention techniques with your doctor so they can tailor your therapy for you. Different diet options, exercise regimens, and goal blood glucose levels may not be right for everyone.

• Intensive control of blood sugar is important in the prevention of diabetic retinopathy, however, it does not guarantee that a individual will not develop the disease.  Factors that can influence an individual’s control of their blood sugars include adhering to a diet and exercise plan determined by your doctor, being compliant with prescribed medications, and glucose monitoring, as well as keeping scheduled doctors visits. One can reduce their risk of retinopathy by 35% per 1 percentage point reduction in A1C.

Current recommendations from the American Diabetes Association are:

-       A1C < 7%

-       Fasting (before a meal) blood glucose 70 to 130 mg/dL

-       Postprandial (1 to 2 hours after a meal) glucose < 180 mg/dL

·      Tight blood pressure control is also important in the prevention of developing the disease and also the progression of the disease. Current American Diabetes Association guidelines recommend a goal blood pressure of  less than 140/80 for individuals with diabetes.

·      Intensive cholesterol control may not have as big an impact as glucose and blood pressure control, but is still be important in the prevention and management of diabetic retinopathy. Current American Diabetes Association guidelines recommend an HDL  greater than 50 mg/dL for women and  greater  than 40 mg/dL for men, and triglycerides less than 150 mg/dL. The goal LDL for individuals who do not have cardiovascular disease, as determined by your doctor, is less than 100 mg/dL, and a goal of less than 70 mg/dL for those diagnosed with cardiovascular disease.

           

Where can I find more information on diabetic retinopathy?

• National Eye Institute's information for individuals can be found at http://www.nei.nih.gov/health/diabetic/eye disease.asp.
• American Diabetes Association information about eye complications can be found at http://www.diabetes.org (in both English and Spanish).

Written by:    Tiffany Chaddick

Doctor of Pharmacy Candidate

College of Pharmacy, University of Illinois at Chicago

UIC Pharmacy

August 2013