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EPILEPSYDr• If the patient is fitting 2 to control the fit. If the patient is not known with epilepsy and has had a fit 2 to assess and manage further.• Epilepsy is a doctor diagnosis in the patient who has had at least 2 definite fits with no identifiable cause or 1 fit following TB meningitis, stroke or head trauma.EPILEPSY: ROUTINE CAREAssess the patient with epilepsyAssess When to assess NoteSymptoms Every visit Manage symptoms as on symptom page.Fit frequency Every visit Review fit diary. Assess if fits prevent patient from leading a normal lifestyle.Adherence Every visit, if fits occur Assess attendance, pill counts and if still fitting on treatment, drug level (doctor decision).Side effects Discuss at diagnosis, every visit Side effects often explain poor adherence. Patient may need to weigh side effects with fit control.Other medication If fits occur Check if patient has started other medication like TB treatment, ART or oral contraceptive. See below.Substance abuse At diagnosis, if fits occurs or adherence poor > 21 drinks/week (man) or > 14 drinks/week (woman) and/or > 5 drinks/session or misuse of illicit or prescription drugs 83.Family planning Every visit • Refer if patient is pregnant or planning to be, for epilepsy and antenatal care.• Assess family planning needs: avoid oral contraceptives on carbamazepine or phenytoin 91.Drug level Only if needed Doctor to check drug level if unsure about adherence or on higher than maximum dose of phenytoin.Advise the patient with epilepsy• Educate about epilepsy and stress the importance of adherence to treatment. Advise patient to keep a fits diary to record frequency dates and times of fits.• Refer for social support if necessary (Epilepsy South Africa) and help patient to get a Medic Alert bracelet back page.• Advise avoiding sleep deprivation, alcohol and drug use, dehydration, flashing lights and video games. These may trigger a fit.• Avoid dangers like heights, fires, swimming alone, cycling on busy roads, operating machinery. Avoid driving until fit free for 1 year.• Advise patient there are many drugs that interfere with anti-convulsant treatment (see below) and to discuss with doctor when starting any new medication.Dr Treat the patient with epilepsy• A single drug is best. Giving 2 anti-convulsant drugs together is a specialist decision.• If still fitting on treatment increase dose only if patient is adherent and there is no substance abuse.• If still fitting after 4 weeks on maximum dose or side effects intolerable, add new drug and increase 2 weekly until fit free. Then taper off old drug over 1 month.Drug Dose NotePhenytoin Starting dose and usual dose: 300mg daily. If not controlled, increase by 50mg 2weekly and check drug level.Carbamazepine Start 100mg 12 hourly. Increase daily dose by 100mg every week until controlled.Usual dose: 300–600mg 12 hourly.Lamotrigine 25mg daily for 2 weeks, then 50mg daily for 2 weeks. Then increase by 50mg 2weekly until controlled. Usual dose: 100–200mg/day as single dose.Avoid in women as it can cause facial hair/coarse facial features. Side effects: skin rash, slurred speech, drowsiness. Druginteractions: isoniazid, warfarin, furosemide, oral contraceptive, ART.Side effects: skin rash, blurred or double vision, ataxia, nausea. Drug interactions: isoniazid, warfarin, fluoxetine, theophylline,amitriptyline, oral contraceptives, ART.Use in HIV. Increase dose if fits on TB treatment or lopinavir/ritonavir. Side effects: skin rash, blurred or double vision. Druginteractions: paracetamol, rifampicin, ART.• If fit free review 6 monthly. Doctor should review monthly the patient who is fitting until fit frequency improves. Refer if still fitting after maximum doses of 2 drugs for 4 weeks each.• Doctor can consider with patient stopping treatment if no fits for 2 years: gradually withdraw 1 drug at a time over 2–3 months.87