FORT CAMPBELL, KY -- As part of Blanchfield Army Community Hospital's Continuing Medical Education (CME) series, the director of Vanderbilt's Epilepsy Center presented a discussion on "Non-Pharmacological Therapy of Epilepsy" during a lunch-and-learn session March 10.
Dr. Bassel W. Abou-Khalil, who also serves as professor of Neurology at Vanderbilt, shared research on dietary therapy, vagus nerve stimulation, and responsive neurostimulation for seizure control. More than 25 providers and nurses attended the lecture, which helps those in the medical field maintain competence and learn about new and developing areas of their field. Since 2009, Vanderbilt Medical Center Staff and Education liaison have donated their time in support of BACH's Hospital Grand Rounds CME program.
"Epilepsy is a common chronic disorder that usually requires long-term antiepileptic drug therapy," Abou-Khalil said. "We always start with medications, but if those medications fail, we must have other options."
He said a recent study of 470 patients showed that about half of patients respond to an initial antiepileptic drug, and about 13 percent respond to a second drug. Only 64 percent were free of seizures at follow-up, highlighting the continued need for more effective and better tolerated drugs or medical therapy.
"Sometimes with diet, patients can reduce or remove medications," Abou-Khalil said. "Dietary therapy, mainly fasting, is a very old treatment of epilepsy dating back to Hippocrates, who described body purification with fasting to treat epilepsy."
A diet of high fat, adequate protein, and low carbohydrates, aptly named ketogenic, was introduced as treatment in 1921 to mimic the effects of fasting. Interest waned after the introduction of antiepileptic drugs, but resurged in the 1990s.
"A ketogenic diet typically begins with fasting and calories are only 75 percent of those recommended by age. The efficacy from long-term studies showed seizure reduction of greater than 90 percent in 37 percent of patients and a 50 to 90 percent reduction in 30 percent of patients," Abou-Khalil said.
Despite the success, adherence to the diet is a major issue in adolescents and young children. "It only takes one cookie to reverse the effects," Abou-Khalil said.
"A modified Atkins diet was created to be more palatable and less restrictive than the ketogenic diet, especially for those who find it hard to comply with the ketogenic. The modified Atkins does not restrict protein or calories; it only restricts carbohydrates."
Overall, both diets proved effective, but compliance is difficult to maintain, Abou-Khalil said. Two additional therapies include vagus nerve stimulation and responsive neurostimulation.
Vagus nerve stimulation (VNS) aims to prevent seizures by using a device similar to a pacemaker to send pulses of electrical energy to the brain via the vagus nerve in the neck. The device gives stimulation at regular intervals during the day, usually with 30 seconds of stimulation alternating with 5 minutes without stimulation. Patients with warnings before seizures can also trigger the device with a special magnet to help stop a seizure or reduce the severity.
"In a study of 100 patients at Vanderbilt, about two-thirds have benefitted with milder or shorter seizures and less frequent destructive seizures resulting in emergency room visits. The ability to stop or influence a seizure with magnet use is the greatest source of satisfaction -- 55 percent say they benefit from magnet use."
Unlike VNS, which uses a small device beneath the skin on the chest, responsive neurostimulation requires a device embedded in the skull with two electrodes implanted within the epileptogenic zone. Seizures are significantly reduced with patients seeing a 53 percent decrease after two years.
"Responsive stimulation is labor intensive and expensive. To be effective, you have to find the source of seizures," Abou-Khalil said.
Treatment of epilepsy continues to require a number of treatment options, and these non-pharmacological therapies are available for patients, he said.
"Lectures like this are great to have, especially if you are clinical staff," said Cpt. Michael Johnson, a neurologist at BACH. "Having this exposure for other staff members to see is super helpful. If you think about nurses, physician assistants, and physical therapists -- if they are familiar with some of the things that are non-pharmacological that we associate with epilepsy, I think that's important that they know other options."
Knowing these other options is especially important with refractory epilepsy, where patients are not responding to conventional therapies, Johnson explained.
"It can prompt them to refer this person to a neurologist, so that improves our access to care. I think that is the most useful thing that we have. Just that alternate treatments come up, that's good because it gets those patients moving in the right direction."
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