Epilepsy - CPPE · 2016-08-30 · Epilepsy – ook 2 2 5 About your focal point event Before coming...

CENTRE FOR PHARMACYPOSTGRADUATE EDUCATION

FP128/2September 2016

A CPPE focal point programme Book 2

Epilepsy

Epilepsy Book 2.indd 1 25/08/2016 10:23

Epilepsy – Book 2

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Content contributorsJuliet Ashton, nurse consultant, epilepsy commissioning and education, Epilepsy SocietyRebecca Case, clinical nurse specialist, University Hospital SouthamptonShelley Jones, neuroscience pharmacist, Kings College Hospital/United Kingdom Clinical Pharmacy AssociationTrudy Thomas, senior lecturer, director of taught graduate studies, Medway School of PharmacyBen Dorward, neuroscience pharmacist, Sheffield Teaching Hospitals/United Kingdom Clinical Pharmacy AssociationDavid Branford, pharmacist advisor for mental health and learning disabilitiesDiar Fattah, head of medicines optimisation, NHS Dartford, Gravesham and Swanley and CPPE tutorGeraldine Flavell, regional manager, CPPERajesh Jethwa, lead pharmacist, Epilepsy Society and the National Hospital for Neurology and Neurosurgery, University College London HospitalsRachel Rose, community pharmacist and CPPE tutorNatasha Ubhoo, community pharmacistTrudi Ward, pharmacy technician lecturer, Birmingham Metropolitan College and CPPE tutor

CPPE programme developer Clare Smith, senior pharmacist, learning development, CPPE

ReviewersBen Dorward, neuroscience pharmacist, Sheffield Teaching Hospitals/United Kingdom Clinical Pharmacy AssociationRajesh Jethwa, lead pharmacist, Epilepsy Society and the National Hospital for Neurology and Neurosurgery, University College London Hospitals

CPPE reviewersPaula Higginson, lead pharmacist, learning developmentAnne Cole, regional manager, South West

Piloted byJanet Rittman, tutor, CPPE

EditorPaddy McLaughlin, assistant editor, CPPE

DisclaimerWe have developed this learning programme to support your practice in this topic area. We recommend that you use it in combination with other established reference sources. If you are using it significantly after the date of initial publication, then you should refer to current published evidence. CPPE does not accept responsibility for any errors or omissions.

External websites CPPE is not responsible for the content of any non-CPPE websites mentioned in this programme or for the accuracy of any information to be found there.

All web links were accessed on 18 August 2016.

Brand names and trademarksCPPE acknowledges the following brand names and registered trademarks mentioned throughout this programme: Buccolam®, Depo-Provera® , Epilim®, Chronosphere®, Epistatus®.

Published in September 2016 by the Centre for Pharmacy Postgraduate Education, Manchester Pharmacy School, The University of Manchester, Oxford Road, Manchester, M13 9PT. www.cppe.ac.uk

ProductionDesign and artwork by Gemini West LtdPrinted by Gemini Print LtdPrinted on FSC® certified paper stocks using vegetable-based inks.

© Copyright Controller HMSO 2016


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Contents

Learning with CPPE 4

About your focal point event 5

Case studies 6

Clinical vignettes 12

Directing change 16

Putting your learning into practice 18

Suggested answers 22

References 46


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Learning with CPPEThe Centre for Pharmacy Postgraduate Education (CPPE) offers a wide range of learning opportunities in a variety of formats for pharmacy professionals from all sectors of practice. We are funded by Health Education England to offer continuing professional development for all pharmacists and pharmacy technicians providing NHS services in England. For further information about our learning portfolio, visit: www.cppe.ac.uk

We recognise that people have different levels of knowledge and not every CPPE programme is suitable for every pharmacist or pharmacy technician. We have created three categories of learning to cater for these differing needs:

Core learning (limited expectation of prior knowledge)

Application of knowledge (assumes prior learning)

Supporting specialties (CPPE may not be the provider and will direct you to other appropriate learning providers).

This is a 2 learning programme and assumes that you already have some knowledge of the topic area.

Continuing professional development - You can use this programme to support your continuing professional development (CPD). Consider what your learning needs are in this area. You can record your CPD online by visiting: www.uptodate.org.uk

Programme guardians - CPPE has a quality assurance process called programme guardians. A programme guardian is a recognised expert in an area relevant to the content of a learning programme who reviews the programme every six to eight months. Following the regular programme guardian review we develop an update to inform you of any necessary corrections, additions, deletions or further supporting materials. We recommend that you check you have the most recent update if you are using a programme more than six months after its initial publication date.

Feedback - We hope you find this learning programme useful for your practice. Please help us to assess its value and effectiveness by visiting your learning record in the My CPPE section on our website: www.cppe.ac.uk/mycppe/record

Alternatively, please email us at: [email protected]

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www.cppe.ac.uk/mycppe/record


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About your focal point eventBefore coming along to this event you will have already completed Book 1 to help you identify your own learning needs, read the key information and then related it to your own area of practice and professional development.

At this event you will work through the case studies and clinical vignettes in this book with your professional colleagues. This will help you apply what you have learnt so far and encourages you to measure the changes in your practice. We also include some suggested answers to the learning activities.

You will have the opportunity to discuss your approach to the Directing change exercise from Book 1. You may be attending a CPPE tutor-led event or have arranged to meet with your own CPPE learning community.

Just to remind you, in this programme we consider:

n the incidence, definition and diagnosis of epilepsy

n the pharmacological and non-pharmacological management of epilepsy

n ways in which to support women considering starting a family, from pre-conception through to pregnancy

n signposting patients living with epilepsy and/or their carers to useful resources.

This is to certify that

attended the CPPE focal point event on epilepsy on

Location

CPPE pharmacy tutor signature

CPPE tutor name


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Case study 1 – Nadeem GopalTime to prepare: 15 minutes to review and answer the questions individually or in small groups.

Time to discuss: 15 minutes to discuss the answers with your colleagues.

Mr Gopal is an 87-year-old man of Indian origin. He lives with his 85-year-old-wife. Eighteen months ago he had a stroke. He made a good recovery but still has some weakness down his right side. His wife comes in to pick up his prescription and mentions that she’s worried about him and wants your opinion. She says that he’s having ‘funny moments’ where he becomes aggressive and makes no sense when he speaks. They last about ten minutes and afterwards he seems confused and can’t remember anything about them. She says he pushed her once and these episodes scare her. They’re happening about once a fortnight.

The prescription she has just collected is for:

Medicine Dose

Simvastatin 20 mg at night

Clopidogrel 75 mg in the morning

Amlodipine 10 mg in the morning

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1. What are the possible causes of Mr Gopal’s ‘funny moments’?



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2. How would you advise and support Mr Gopal’s wife?

On your advice Mr Gopal goes to see his GP who refers him to neurology, where he is diagnosed with focal epilepsy. Mrs Gopal comes in with a prescription for carbamazepine 400 mg twice daily, issued by the GP.

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3. What are the main concerns regarding Mr Gopal’s treatment and how would you address them?

The GP amends the prescription to a slow-release preparation of carbamazepine 200 mg once a day and gives a titration schedule. The plan is to increase the dose in steps of 200 mg every two weeks to a target dose of 400 mg twice a day.


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Three weeks later Mrs Gopal comes in again; she says that Mr Gopal hasn’t had another ‘funny turn’ but that he’s complaining of double vision in the mornings. Mrs Gopal goes on to say that Mr Gopal has stumbled a couple of times and fallen once, and she wasn’t able to get him up. She’s quite stressed and says that getting old is no fun, it’s one thing after another and they both take so many tablets that all look the same.

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4. What are the main concerns regarding Mr Gopal? How would you address them?



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Case study 2 – Jessica HoTime to prepare: 15 minutes to review and answer the questions individually or in small groups.


Jessica Ho is an 18-year-old woman, diagnosed with juvenile myoclonic epilepsy aged 13. She has tonic-clonic seizures (one each month on average). She also has frequent myoclonic jerks, occurring most mornings in the first couple of hours after waking, and sometimes in the evening when she’s tired. Jessica has been under paediatric services and is transitioning to adult neurology services. Her adult neurologist wants to add in levetiracetam to her current lamotrigine monotherapy to try and get her seizures under control. She is going to be leaving home and attending university in a couple of months’ time.

Current medicine: lamotrigine 250 mg twice a day

Proposed addition: levetiracetam 500 mg twice a day

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1. What are the key points that need to be considered?

Jessica comes into the pharmacy with her mum. She is subdued and doesn’t talk. Her mum says she’s read about the new medicine on the internet and has seen that one of the side effects is low mood. She’s concerned as “Jess already has mood swings and a short temper. She spends most of her time in her room.”


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2. What are the issues that need to be considered?

You take Jessica to the consultation room alone and she tearfully discloses that epilepsy is ruining her life. She can’t drive and her mum is so overprotective that she has no life. She says that she often misses doses of lamotrigine and doesn’t want to have another medicine as well.

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3. What questions would you ask Jessica?

With Jessica’s permission you contact her GP to discuss whether the addition of levetiracetam is necessary now that Jessica has disclosed that she is not always taking her lamotrigine. Jessica’s GP thanks you for this information and agrees to contact her neurologist.



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You hear nothing more for some time. In the Christmas holidays Jessica returns from university and comes in on her own to pick up a prescription. She remembers you and tells you that she loves university and has a boyfriend, who encourages her to take her medicines. As a result her seizures are much improved and she only has them after she’s drunk too much or she’s been “burning the candle at both ends”. She explains that her neurologist didn’t start her on the new medicine in the end.

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4. After speaking to Jessica, what are the main risk factors you would like to address, and what advice and support can you give?


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Clinical vignettesTime to prepare: 15 minutes to review and answer the questions individually or in small groups.


In this section of focal point we look at brief clinical scenarios and particularly focus on decision-making, communication and taking a patient-centred approach. Review each of the clinical vignettes and come up with a suitable response to manage the situation. You may wish to practise these responses using role play.

Clinical vignette 1

Katherine Field, a 27-year-old woman, comes into the pharmacy with a prescription for sodium valproate. She explains that she regularly had seizures as a child, but until last week she hadn’t had one in the last three years. She decided to stop her sodium valproate three months ago due to weight gain (two stone) and after reading some information online around polycystic ovarian syndrome (PCOS). Her GP has advised her to restart the sodium valproate.

“I know that the GP says that I need to start taking this medicine again, but I’m not sure. Can you offer some advice on what other alternatives are available?”

Construct a response to Katherine using the words you would use in the consultation.



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Clinical vignette 2

Shafiq Khan has come in to the pharmacy with his three-year-old son, Ahmed. Mr Khan looks in a very anxious state. Ahmed has Down’s syndrome and was also diagnosed with epilepsy around 18 months ago.

Mr Khan explains that for the past week Ahmed has been spitting out his sodium valproate oral solution, and then last night he had a seizure.

“I am really worried about my son having another seizure. But I cannot stop him from spitting out the medicine. I just don’t know what to do!”

Construct a response to Mr Khan using the words you would use in the consultation.

Clinical vignette 3

You are conducting an MUR on Mrs Antonia Kelly who is 75 years old. She is on many medicines following her stroke last year. During the MUR you ask about her phenytoin use. She says she was started on 25 mg following the stroke, which was recently increased to 50 mg.

“Well, I am a bit worried really, as I feel drowsy in the morning when I wake up, and getting around with my walking stick is getting quite difficult.”

Construct a response to Antonia using the words you would use in the consultation.


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Clinical vignette 4

Dr Jones calls you on Friday afternoon about his patient Christopher Walsh. He explains that Christopher is on levetiracetam 500 mg twice a day. He wants advice about the prescription your pharmacy supplied to Christopher last month.

“Christopher is concerned as he always gets his prescription from you, and every time he has received a large peach-coloured tablet. Last time he picked up his medicines his tablet was smaller and white in colour. This is causing him to be more anxious, and I am worried this could bring on a seizure.”

Construct a response to Dr Jones using the words you would use in this scenario.



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Visit the Consultation skills for pharmacy practice website to develop your consultation skills and learn more about taking a patient-centred approach.

www.consultationskillsforpharmacy.com


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Directing changeTime to prepare: none – you should have done this before the event.Time to discuss: 15 minutes to discuss the answers with your colleagues.

Revisit the notes you made in the Directing change section of Book 1. Discuss the solutions and ideas you developed with your colleagues. What would you do differently now as a result of your learning?

You have reached the end of the activities for this focal point event; the remainder of this book contains follow-up activities and the suggested answers. You may wish to spend some time after the event looking through these with colleagues.



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After your focal point event: putting your learning into practice

Now it is time to assess your learning, determine your readiness to change and put your new knowledge into practice.


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Putting your learning into practiceThere are four actions you should undertake to ensure that what you have learnt in this focal point programme influences your future practice.

1. Work through the practice activities listed below

2. Evaluate your learning by revisiting the Moving into focus questions

3. Complete the CPPE online e-assessment

4. Reflect on the steps for change outlined on page 21

1. Practice activities (45 minutes)

You might wish to start to put some of your learning into practice by undertaking the following activities.

n Have a look at the information for pharmacists on the Epilepsy Society website at www.epilepsysociety.org.uk and work with your pharmacy team to identify and decide which resources will be helpful for your patients and their families. Obtain these resources and display them in your pharmacy or practice.

n Identify current patients with epilepsy that might benefit from an MUR, and use the medicine use review – epilepsy consultation brief to help you support your patents during the consultation. www.epilepsysociety.org.uk/sites/default/files/attachments/epilepsyMURconsultationbrief.pdf

n Develop a local contact list for individuals or organisations involved in supporting patients and carers or families with epilepsy in your local area.

When will you complete these activities?


https://www.epilepsysociety.org.uk/sites/default/files/attachments/epilepsyMURconsultationbrief.pdf


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2. Evaluate your learning (15 minutes)

The second step is to revisit the Moving into focus questions.

1. Would you know how to help a patient having a seizure? Watch this video produced by Epilepsy Action to find out more: www.epilepsy.org.uk/involved/campaigns/take-epilepsy-action

2. Why is dose titration usually needed when antiepileptic drugs (AEDs) are prescribed?

3. Evelyn Hughes is one of your regular patients. She has asked for somebody to review her epilepsy medicines. How confident do you feel carrying out a review of Mrs Hughes’ medicines? Where would you look to find appropriate information to support you?

Continued on next page


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4. Aleksy Kowalski, a 21-year-old man, is a regular patient at your pharmacy, having been diagnosed with epilepsy two years ago. He tells you he has been forgetting to take his medicines at times and has recently had a few seizures as a consequence. How could you help him to remember to take them?

5. Where can you signpost patients with epilepsy and their carers for further support and services?

Can you answer these questions now?

3. Access assessment (30 minutes)

The next step in assessing your learning is to access the online e-assessment on our website. To access the assessment, go to: www.cppe.ac.uk/assessment

If you complete the e-assessment successfully you will be able to print your own certificate of achievement.

When will you access the e-assessment?



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4. Reflection – steps for change (15 minutes)

The final step is to think about the following statements and note down how you feel about them. This should help you determine any requirements for your further development.

I have achieved my personal learning objectives that I set myself on page 13 in Book 1.

Strongly disagree Disagree Agree Strongly agree

I have identified additional learning I need to undertake to improve my knowledge of the management of epilepsy.


I would like to follow up a best practice idea expressed by a colleague at the focal point event/within my learning community.


I would like to find out what resources and support are available in my local area to help improve communication and support for patients with epilepsy.


After reflecting on these statements, what steps will you take now to make them reality?


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Suggested answers to:n Moving into focus questions

n Practice points

n Talking points

n Case studies

n Clinical vignettes

Please remember that these answers are suggestions only. You should refer to local guidelines when monitoring patients’ epilepsy therapy.



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These are the authors’ suggested responses to the learning activities and they should be used as a guide during your focal point event. Where possible, use your own local guidelines and policies to inform the discussion and answers. We have provided short answers to the questions, case studies and clinical vignettes and, where appropriate, these are followed by discussion points that provide a little more detail.

Moving into focus1. Would you know how to help a patient having a seizure? Watch

this video produced by Epilepsy Action to find out more: www.epilepsy.org.uk/involved/campaigns/take-epilepsy-action

Think about what you and your team could do to support somebody having a tonic-clonic seizure. Do you have a seizure response plan in place?

Developing a seizure response plan helps to emphasise the important role each team member can play in the management of seizures. Having a plan in place can help to organise information, and have it available to all team members when it’s needed.

The Epilepsy Action charity produced a poster as part of the Take epilepsy action campaign, which aims to raise awareness of how people can help somebody having a seizure and the relevant first aid steps they should take.

www.epilepsy.org.uk/sites/epilepsy/files/epilepsyaction-take-epilepsy-action-a3poster.pdf

Remember ACTION for tonic-clonic seizures:

A Assess the situation – are they in danger of injuring themselves? Remove any nearby objects that could cause injury.

C Cushion their head (with a jumper, for example) to protect them from head injury.

T Time – Check the time – if the seizure lasts longer than five minutes you should call an ambulance.

I Identity – Look for a medical bracelet or ID card – it may give you information about the person’s seizures and what to do.

O Over – Once the seizure is over, put them on their side (in the recovery position). Stay with them and reassure them as they come round.

N Never restrain the person, put something in their mouth or try to give them food or drink.


https://www.epilepsy.org.uk/sites/epilepsy/files/epilepsyaction-take-epilepsy-action-a3poster.pdf

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2. Why is dose titration usually needed when antiepileptic drugs (AEDs) are prescribed?

Most AEDs have the potential to cause side effects of the central nervous system (CNS) in a dose-dependent manner. The general principle of treating epilepsy is to start at a low dose and increase gradually until seizures are controlled or side effects become unmanageable.

Discussion pointsn Common side effects can include drowsiness, dizziness, ataxia and

headache.

n For some medicines like carbamazepine and lamotrigine, rapid titration can increase the risk of developing rashes. These reactions are unrelated to their mechanism of action but more likely a reflection of their chemical structure. Any patient reporting a rash with an AED should be referred urgently to the GP.

n If seizures are controlled at a given dose then no further dose increase should be given, ie there is no need to increases doses to in order to ‘get people in range’.

n If seizures are not controlled at the initial dose then further dose increases should be undertaken slowly at one-two month intervals, giving each dose increment a reasonable trial before a further increase is considered.

3. Evelyn Hughes is 79 and one of your regular patients. She has asked for somebody to review her epilepsy medicine as she is getting confused. How confident do you feel carrying out a review of Mrs Hughes’ medicines? Where would you look to find appropriate information to support you?

Many patients with epilepsy would benefit from medicines use reviews (MUR) and yet many are not offered them. Pharmacy professionals can use a consultation brief designed by PSNC and the Epilepsy Society to develop their knowledge and confidence in providing MURs with their patients.

www.epilepsysociety.org.uk/sites/default/files/attachments/epilepsyMURconsultationbrief.pdf

The consultation brief guides pharmacists through the MUR process, and can provide suggested questions and prompts to be used during the consultation.


https://www.epilepsysociety.org.uk/sites/default/files/attachments/epilepsyMURconsultationbrief.pdf


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Discussion pointsUsing open style questions within the consultation can help to ascertain what issues, if any, Mrs Hughes may have. Consider using questions like:

n Tell me how your medicines fit in to your day?

n Do you have any concerns about your medicines?

Other points to cover may include:

n is the patient still experiencing seizures (when was the last one?)

n are they seeing a specialist for the management of their epilepsy (when is the next appointment?)

n are there any physical barriers stopping them taking their medicines? For instance, difficulty in opening packets, swallowing tablets or reading labels.

n What additional support does the patient need? For example, referral, more education, signposting, compliance aids.

n Has the patient ever carried out a risk assessment to help identify what their risks are? You can signpost people to the Epilepsy Society website where they can access forms to check their level of risk: www.epilepsysociety.org.uk/risk-assessment

4. Aleksy Kowalski, a 21-year-old man, is a regular patient at your pharmacy, having been diagnosed with epilepsy two years ago. He tells you he has been forgetting to take his medicines at times and has recently had a few seizures as a consequence. How could you help him to remember to take them?

The first step is to understand why Aleksy is forgetting to take his medicine. Explore the reasons why he’s forgetting; are there any lifestyle factors, or physical barriers stopping him from taking his medicine? Think about timings of medicines; is there a particular time of day that is more convenient for him to remember to take them? By involving Aleksy at every stage of the consultation, and exploring his beliefs and concerns you can gain an understanding of what he already knows, and offer options or solutions.

Discussion pointsn Epilepsy, seizures and some AEDs can all have an effect on memory.

Memory aids such as medicine dosette boxes and alarm reminders may help patients to remember their medicines.



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n Switching to twice daily or slow release formulations can help to reduce the number of times medicines need to be taken during the day.

n Cues to help with remembering to take AEDs at the same time each day.

n Support from parents and carers may help to improve adherence.

n Introducing technology to aid in adherence. The Epilepsy Society has a mobile phone app to help patients to remember to take their medicines.

n Signposting to local and national help groups for further advice and support.

5. Where can you signpost patients with epilepsy and their carers for further support and services?

Epilepsy can affect every part of a person’s life, including physical and mental health, quality of life, education and employment, finances and economic status, marital status and more. Epilepsy can also affect carers and families. As a result, signposting may be to a number of organisations/sources of support and not just epilepsy services1.

Discussion pointsThe two main epilepsy charities have helplines, patient forums and local groups, as well as a wealth of information.

n Epilepsy Action – www.epilepsy.org.uk

n Epilepsy Society – www.epilepsysociety.org.uk

There may also be local charities and organisations that people can access, as well as national organisations. Local groups may include:

n good neighbour services, which include befriending and aiding people to get to appointments

n charitable funding organisations

n relationship guidance

n family planning services

n local mental health teams/groups

n carer support groups

n employment agencies.

Take a look at the ‘Useful resources’ section for more information on signposting.



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Practice and talking pointsTalking point A

How do patients feel when they are having a seizure? Watch this series of videos produced by the Epilepsy Society to gain an insight into the different types of seizures, and how they can affect people. Do any of them surprise you?

www.epilepsysociety.org.uk/seizure-types-videos

Practice point 1

A patient comes into your pharmacy and explains that they have had a funny turn. They are worried they may have had a seizure. What type of questions could you ask the patient to help you distinguish between a funny turn and a seizure?

By asking the patient open or probing questions, you can gain an understanding of what has happened. Using this type of questioning allows the patient to give an unlimited range of answers, and can help you reach the desired outcome.

A common tool used to probe or dig a little deeper is TED. TED outlines three common ways to start a question:

T – tell

“Tell me more about...”

E – explain

“Explain to me why...”

D – describe

“Can you describe to me...”



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Discussion pointsIn 2010, NICE produced guidance that can help to distinguish between a funny turn (blackout) and a seizure: transient loss of consciousness (TLoC) (‘blackouts’) in adults and young people (CG109).

The guidance states that people who present with one or more of the following features, are more suggestive of epileptic seizures:

n A bitten tongue

n Head-turning to one side during the episode

n No memory of abnormal behaviour that was witnessed before, during or after the episode by someone else

n Unusual posturing

n Prolonged limb-jerking (note that brief seizure-like activity can often occur during uncomplicated faints)

n Confusion following the event

n Prior déjà vu.

And that the episode may not be related to epilepsy if any of the following features are present:

n Prior symptoms that on other occasions have been abolished by sitting or lying down

n Sweating before the episode

n Prolonged standing that appeared to precipitate the episode

n Pallor during the episode.

Practice point 2

A patient with epilepsy presents with their first prescription for Epistatus® (buccal midazolam), 10 mg to be administered when required as directed.

In discussing this medicine with the patient and their carer(s), what advice would you offer?

Midazolam is a benzodiazepine and is given via the buccal cavity in status epilepticus (a medical emergency). This is where a person has a seizure or a series of seizures that are prolonged.

When consulting with a patient and their carer(s) you should:

n ask if there is a written care plan which states in what circumstances



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buccal midazolam is to be used, what dose to be administered, and when to call an ambulance if it does not work

n ask if they and their carers know what dose to use and how to prepare this dose.

People should be reminded to regularly check the expiry date and to always make sure that they have a supply in case it is needed.

Discussion pointsn It is a NICE quality standard (QS 26/27) that patients have written care plans.

n Buccal midazolam is available as:

n Buccolam® contains midazolam hydrochloride 5 mg in 1 ml, in pre-filled oral syringes of 2.5 mg, 5 mg, 7.5 mg and 10 mg.

n Epistatus® contains midazolam maleate 10 mg in 1 ml. It is a preparation in a 5 ml bottle with four oral syringes in the packaging. Epistatus® is also available as pre-filled oral syringes of 2.5 mg, 5 mg, 7.5 mg and 10 mg. This is an unlicensed product, available as a ‘special’2.

n It is important to remember which brand and dose is used.

n The main treatment of status in the community is now buccal midazolam and carers can be trained to administer it. This has replaced rectal diazepam as this route was found to be unacceptable to many patients.

Talking point B

You are conducting a consultation with one of your patients with epilepsy who also has a learning disability. What factors would you need to consider to engage and support the patient during the consultation?

In the management of people with a learning disability and epilepsy, reasonable adjustments need to be made to ensure that all people have the same opportunity for health. Examples are:

n Adequate time to be allowed for the consultation

n Communicate with the person with the learning disability first and involve them as much as possible

n The carer should know the patient and bring relevant information on seizure type, frequency, possible adverse effects of medicines, general health and behaviour to the consultation



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n Information in an accessible form is to be available

n Use language that the person understands, or use a communication aid, ie, pictures or symbols.

The Pharmaceutical Journal published an article which addresses the need to overcome the barriers to effective consultations with adults with learning disabilities. It covers the challenges that may occur, while also offering practical ways to improve pharmacy consultation skills: www.pharmaceutical-journal.com/learning/learning-article/pharmacy-consultations-with-patients-with-learning-disabilities/20200330.article

Discussion pointsn It is important to consider mental capacity. The Mental Capacity Act 2005

states “A person lacks capacity in relation to a matter if, at the time, they are unable to make a decision for themselves in relation to the matter, because of an impairment of, or a disturbance in, the functioning of the mind or brain3.”

n There should be a multidisciplinary approach to treatment, delivered by professionals with an expertise in epilepsy, to improve quality of life. Community learning disability nurses have an important role in liaising between the specialist services, patients and carers.

Practice point 3

As a pharmacy professional how can you and your team help a patient to remember to stick to their AED treatment?

You can optimise adherence to treatment by4:

n educating children, young people and adults and their families and/or carers in the understanding of their condition and their particular treatment

n helping to reduce the stigma associated with the condition

n using simple medicine regimens

n encouraging positive relationships between healthcare professionals, the patient, their family and/or carers.


http://www.pharmaceutical-journal.com/learning/learning-article/pharmacy-consultations-with-patients-with-learningdisabilities/20200330.article


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Discussion pointsn Pharmacy professionals can also help with developing cues for

remembering when to take doses, such as using phone alarms or compliance aids.

n Discussing side effects with patients, and then addressing any concerns they may have, can also help to optimise adherence.

n Remember that non-adherence is common, both intentional and non-intentional. By showing a non-judgemental attitude, and openly discussing a patient’s beliefs, concerns or problems. pharmacy professionals can support patients to make the most effective use of their medicines.

n Patients with long term conditions can also be referred to the Expert Patients Programme, where they can find tools and techniques to help them manage their condition more effectively – www.expertpatients.co.uk


Epilepsy – Book 2

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1. What are the possible causes of Mr Gopal’s ’funny moments’?

�n Focal epilepsy

n Transient ischaemic attack (TIA)

n Mood disorder

n Dissociative seizures

n Dementia

n Brain tumour

Discussion points

n Further tests will need to be carried out by the GP or specialist to be able to diagnose what has caused Mr Gopal’s recent changes in behaviour.

n Epilepsy in older people may be associated with dementia or cerebral degeneration. Seizures may present as focal seizures and can often be mistaken for other conditions.

n There are often other complications to be considered in older people, such as seizures that cause falls being more likely to cause injury.

Case study 1 – Nadeem GopalMr Gopal is an 87-year-old man of Indian origin. He lives with his 85-year-old-wife. Eighteen months ago he had a stroke. He made a good recovery but still has some weakness down his right side. His wife comes in to pick up his prescription and mentions that she’s worried about him and wants your opinion. She says that he’s having ‘funny moments’ where he becomes aggressive and makes no sense when he speaks. They last about ten minutes and afterwards he seems confused and can’t remember anything about them. She says he pushed her once and these episodes scare her. They’re happening about once a fortnight.

The prescription she has just collected is for:

Medicine Dose

Simvastatin 20 mg at night

Clopidogrel 75 mg in the morning

Amlodipine 10 mg in the morning



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�At this point we need to consider the safety of Mrs Gopal, by offering advice on how she can manage these episodes, and where she can get support if she is struggling.

We also should encourage her to get Mr Gopal to see his GP, who can then refer him to the relevant specialist for a thorough assessment.

Discussion points

n Does Mrs Gopal have any close relatives at home that can support her?

n Are there any safeguarding issues that we need to act on?

n Consider the words we use, and the tone of voice. By showing empathy to Mrs Gopal’s situation we can help to build rapport.

On your advice Mr Gopal goes to see his GP who refers him to neurology, where he is diagnosed with focal epilepsy. Mrs Gopal comes in with a prescription for carbamazepine 400 mg twice daily, issued by the GP.

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3. What are the main concerns regarding Mr Gopal’s treatment and how would you address them?

�The carbamazepine has not been prescribed as a slow-release formulation, as recommended by NICE.

Is the starting dose correct, and why is there no titration advice given?

Explain to Mrs Gopal that you want to clarify some information with the GP, and that you will need to make a telephone call. If this intervention takes a while, you can offer to contact Mrs Gopal once you have spoken to Mr Gopal’s GP.

Discussion points

n There is an issue of confidentiality, as you haven’t spoken to Mr Gopal directly.

n How quickly would you be able to speak to the GP regarding the prescription, and then collect any subsequent prescriptions?



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n In this case the starting dose is higher than recommended. It is essential to initiate carbamazepine therapy at a low dose and build this up slowly with increments of 100–200 mg every two weeks. Some side effects (such as headache, ataxia, drowsiness, nausea, vomiting, blurring of vision, dizziness, unsteadiness, and allergic skin reactions) are dose-related, and may be dose-limiting. These side effects are more common at the start of treatment and in the elderly. Patients should be offered a modified-release preparation to reduce the risk of side effects.

n It is worth finding out if Mr Gopal has any difficulties with opening boxes, popping medicines out of blister packs, swallowing the medicine or any other physical barriers that may reduce his adherence to the medicine.

n There are many drug interactions with carbamazepine so it is important to establish everything that Mr Gopal is taking, including over-the-counter medicines, so that you can check for any possible drug interactions.

The GP amends the prescription to a slow-release preparation of carbamazepine 200 mg once a day and gives a titration schedule. The plan is to increase the dose in steps of 200 mg every two weeks to a target dose of 400 mg twice a day.

Three weeks later Mrs Gopal comes in again; she says that Mr Gopal hasn’t had another ‘funny turn’ but that he’s complaining of double vision in the mornings. Mrs Gopal goes on to say that Mr Gopal has stumbled a couple of times and fallen once, and she wasn’t able to get him up. She’s quite stressed and says that getting old is no fun, it’s one thing after another and they both take so many tablets that all look the same.



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4. What are the main concerns regarding Mr Gopal? How would you address them?

�The side effects that Mrs Gopal is reporting are often associated with elevated drug serum concentration levels. As Mr Gopal has only been taking the carbamazepine for three weeks, he should not have yet reached the target dose of 400 mg twice a day, but he will be on a therapeutic dose.

Mr Gopal should be referred back to the GP as soon as possible for further consultation.

You should advise Mrs Gopal to not increase Mr Gopal’s dose of carbamazepine any further, until they have seen the GP.

Discussion points

n Has Mr Gopal understood how to increase the dose of his medicine correctly? Is there a possibility he is taking too high a dose too quickly?

n The side effects reported can increase the likelihood of falls, which for Mr Gopal, could pose an even greater risk.

n Is Mr Gopal hypotensive due to amlodipine? This could be a contributing factor to his recent stumbles or fall.

n Would Mr Gopal benefit from the use of a compliance aid such as a dosette box, or medicine wallet?

n Consider offering Mr Gopal a review of his medicines so he has a better understanding of how and when to take them.


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1. What are the key points that need to be considered?

�Transition process from child to adult neurology services – is it meeting her needs and does the new neurologist have enough information about her?

What support will she need when she leaves home and goes to university?

Be mindful that Jessica’s lifestyle may change once she goes to university. Change in stress levels, alcohol consumption, sleeping patterns, caffeine consumption, skipping meals and recreational drug use can all increase the possibility of a seizure.

Discussion points

n Implications of adding in an adjunctive therapy could possibly cause an increase in side effects. If this is then coupled with a large change in her social circumstances Jessica may become non-adherent or experience an increase in her seizures.

n Levetiracetam should be introduced at a low dose and titrated up slowly over a matter of weeks. The BNF states that the initial starting dose should be 250 mg once daily increased after one-two weeks to 250 mg twice daily. Then the dose is to be increased according to response in steps of 250 mg twice daily every two weeks to the desired dose (to a maximum dose of 1.5 mg twice a day).

Case study 2 – Jessica HoJessica Ho is an 18-year-old woman, diagnosed with juvenile myoclonic epilepsy aged 13. She has tonic-clonic seizures (one each month on average). She also has frequent myoclonic jerks, occurring most mornings in the first couple of hours after waking, and sometimes in the evening when she’s tired. Jessica has been under paediatric services and is transitioning to adult neurology services. Her neurologist wants to add in levetiracetam to her current lamotrigine monotherapy to try and get her seizures under control. She is going to be leaving home and attending university in a couple of months’ time.

Current medicine: lamotrigine 250 mg twice a day

Proposed addition: levetiracetam 500 mg twice a day



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Jessica comes into the pharmacy with her mum. She is subdued and doesn’t talk. Her mum says she’s read about the new medicine on the internet and has seen that one of the side effects is low mood. She’s concerned as “Jess already has mood swings and a short temper. She’s spends most of her time in her room.”

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2. What are the issues that need to be considered?

�Confidentiality needs to be addressed. Jessica is an adult, and may not want to have her mum involved in any discussions around her medicines or side effects.

Where has Jessica’s mum found out the information that she is concerned about? It can be difficult for patients to have the correct facts around their medicines when they search for information on the internet.

Discussion points

n Remember that family dynamics can have an effect on relationships, and Jessica may not have issues with her medicines or epilepsy, but may have issues with her mum, or other members of the family.

n Offer a private consultation to Jessica, to let her expand on the information raised by her mum. This may give a more informed picture of how Jessica is feeling.

n Signpost Jessica and her mum to good quality websites and support groups to find out more information on her condition and medicines.

n Seek Jessica’s opinion on the changes to her medicines to help you build rapport while encouraging her to take more responsibility for her own health.

You take Jessica to the consultation room alone and she tearfully discloses that epilepsy is ruining her life. She can’t drive and her mum is so over protective that she has no life. She says that she often misses doses of lamotrigine, and doesn’t want to have to take another medicine as well.



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3. What questions would you ask Jessica?

�n What would you like to find out from me today?

n Tell me what you already know about your epilepsy and your medicines.

n Is there anything else you would like to know about your medicines?

n Do you have any concerns regarding your epilepsy, treatment or going to university?

n What do you expect from your treatment?

n Tell me why you miss some of your doses.

Discussion points

n By asking Jessica what she would like from the consultation, finding out what she already knows and what she would like to know, you are taking a patient-centred approach and encouraging Jessica to be an equal partner in the consultation. Exploring her ideas, concerns and expectations (ICE) about her treatment provides a structured approach to the consultation.

n If Jessica is not consistently taking her lamotrigine, is the levetiracetam still indicated?

n What support is available to Jessica given that she is moving out of the area, but her neurology services remain in this area?

n Think about how you might change your consultation style when speaking with young adults. How can you engage them effectively in the consultation, and how would you deal with any possible conflict if there was also a parent or carer involved?

n Jessica is a young woman of child-bearing age and is leaving home for the first time to go to university. At this time Jessica may start thinking about contraception, and so needs to be made aware of the possibility of a drug interaction between lamotrigine and hormonal contraception, and of the need to check with her doctor before she thinks about choosing the right contraception for her. You could signpost Jessica to: NHS Choices: www.nhs.uk/Conditions/Epilepsy/Pages/living-with.aspx or The Epilepsy Society: www.epilepsysociety.org.uk/contraception-and-epilepsy


http://www.nhs.uk/Conditions/Epilepsy/Pages/living-with.aspx

https://www.epilepsysociety.org.uk/contraception-and-epilepsy#.V8AIiIXXxDE


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With Jessica’s permission you contact her GP to discuss whether the addition of levetiracetam is necessary now that Jessica has disclosed that she is not always taking her lamotrigine. Jessica’s GP thanks you for this information and agrees to contact her neurologist.

You hear nothing more for some time. In the Christmas holidays Jessica returns from university and comes in on her own to pick up a prescription. She remembers you and tells you that she loves university and has a boyfriend, who encourages her to take her medicine. As a result her seizures are much improved and she only has them after she’s drunk too much or she’s been burning the candle at both ends. She explains that her neurologist didn’t start her on the new medicine in the end.

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4. After speaking to Jessica, what are the main risk factors you would like to address, and what advice and support can you give?

Risk factors:

�n Alcohol consumption

�n Sleep deprivation

�n Stress of exams/study

�n Living alone

�n Interaction between lamotrigine and hormonal contraception.

Offer advice on medicine reminders to aid adherence.

Does Jessica have a supportive network at university? Has she found out about any epilepsy support networks in her area?



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Discussion points

Jessica may not be aware of the risk factors for sudden unexplained death in epilepsy (SUDEP). SUDEP risk is increased by young adulthood, ongoing seizures, tonic-clonic seizures, night seizures and living alone. Getting the best seizure control possible is a positive way to reduce risks.

You can advise Jessica that she can increase her seizure control by:

n taking her AEDs consistently and around the same time each day

n advising Jessica to keep a diary of when her seizures happen. This will help to show if there is a pattern to her seizures and whether any situations trigger them (like being tired or stressed). It might also be useful to see how well her medicines are working to control these seizures. An electronic seizure diary can be downloaded from the Epilepsy Society website: www.epilepsysociety.org.uk/sites/default/files/attachments/SeizurediaryA4versionJuly2015.pdf

n using a seizure alarm that alerts someone when a seizure is occurring

n using safety or ‘anti-suffocation’ pillows, which have holes in them for ventilation to help reduce risk of SUDEP for night seizures.

You can find out more about alarms and safety aids on the Epilepsy Society website: www.epilepsysociety.org.uk/alarms-and-safety-aids

Jessica has also mentioned she has a boyfriend, and so it would be an appropriate time to remind her about the importance of contraception and offering her an opportunity to ask any questions.


https://www.epilepsysociety.org.uk/sites/default/files/attachments/SeizurediaryA4versionJuly2015.pdf


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Clinical vignettesClinical vignette 1

Katherine Field, a 27-year-old woman, comes into the pharmacy with a prescription for sodium valproate. She explains that she regularly had seizures as a child, but until last week she hadn’t had one in the last three years. She decided to stop her sodium valproate three months ago due to weight gain (two stone) and after reading some information online around polycystic ovarian syndrome (PCOS). Her GP has advised her to restart the sodium valproate.

“I know that the GP says that I need to start taking this medicine again, but I’m not sure. Can you offer some advice on what other alternatives are available?”

Construct a response to Katherine using the words you would use in the consultation.

The bottom line:

Offer Katherine the opportunity to have a more in-depth conversation in the consultation room, concentrating on the issues she has mentioned and how they are having a negative impact on her life.

Why?

It is important to let Katherine express her concerns about her medicine. Find out what information she already knows, and then be ready to offer suitable options or solutions to her concerns.

Supporting the statements

n Sodium valproate use has been associated with worsening of PCOS symptoms and may cause menstruation irregularities.

n Choice of AED depends on different factors, and should be individualised to the patient.

n A pharmacy professional’s main role in this situation will be to listen to Katherine’s concerns and try to allay any fears she may have by offering correct information about her medicines. Katherine should then be referred back to her GP or neurologist to have her current medicines reviewed. They can then work in partnership to come up with a more suitable treatment plan. See Section 2: Management of epilepsy in Book 1 for more information.

n If Katherine drives, the DVLA recommend that patients should be advised to not drive during medicine changes or withdrawal of AEDs, and for six months afterwards.


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Clinical vignette 2

Shafiq Khan has come in to the pharmacy with his three-year-old son, Ahmed. Mr Khan looks in a very anxious state. Ahmed has Down’s syndrome and was also diagnosed with epilepsy around 18 months ago.

Mr Khan explains that for the past week Ahmed has been spitting out his sodium valproate oral solution, and then last night he had a seizure.

“I am really worried about my son having another seizure. But I cannot stop him from spitting out the medicine. I just don’t know what to do!”

Construct a response to Mr Khan using the words you would use in the consultation.

The bottom line:

It is important for Ahmed to take his AEDs regularly to help minimise the frequency of his seizures.

Why?

Risk of SUDEP is greater in people with a learning disability and epilepsy (for more information about SUDEP, see section 4.1 in Book 1), and poor adherence to medicines is a risk factor of SUDEP.


n When was the last time Ahmed had a review with his GP or specialist? A dose increase may be necessary if he has grown significantly in that time.

n Consider whether the dose has recently been increased; Ahmed may be finding it more difficult to swallow an increased volume of liquid.

n Has Ahmed been given a different brand of sodium valproate oral solution? Any change of taste, texture or smell may cause him to spit out his medicine.

n Consider how Mr Khan is administering the oral solution: has he changed the spoon or syringe, which may have caused Ahmed to think the medicine has changed?

n Consider speaking to Ahmed’s GP to see if the sodium valproate could be changed to a different formulation. Another formulation that may be more suitable is crushable tablets. If Ahmed needs a modified release version, then Epilim® Chronospheres® have been designed to be able to mix with soft food or drink.



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Clinical vignette 3

You are conducting an MUR on Mrs Antonia Kelly who is 75 years old. She is on many medicines following her stroke last year. During the MUR you ask about her phenytoin use. She says she was started on 25 mg following the stroke, which was recently increased to 50 mg.

“Well, I am a bit concerned really, as I feel drowsy in the morning when I wake up, I sometimes get quite confused and getting around with my walking stick is getting quite difficult.”

Construct a response to Mrs Kelly using the words you would use in the consultation.

The bottom line

Is Mrs Kelly showing signs of phenytoin toxicity?

Why?

Phenytoin has a narrow therapeutic index and the relationship between dose and serum drug concentration is non-linear (small dose increases in some patients can produce large increases in serum concentration which can cause toxic side effects). Although the dose of phenytoin is very low, there may be drug interactions with Mrs Kelly’s other medicines, causing an increased serum concentration of phenytoin.


n When was the last time Mrs Kelly had her phenytoin serum concentration checked? Regular monitoring is recommended.

n Check for drug interactions with Mrs Kelly’s other medicines.

n Different formulations of oral preparations may vary in bioavailability. Patients should be maintained on a specific manufacturer’s product, to reduce the chance of subtherapeutic or toxic serum concentrations.

n Consider vitamin D supplementation for Mrs Kelly. Patients who are immobilised for long periods, or who have inadequate sun exposure or dietary intake of calcium, are at risk as phenytoin can be detrimental to bone health.

n Phenytoin can also cause folate deficiency so Mrs Kelly should have her folate serum concentration checked periodically.


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Clinical vignette 4

Dr Jones calls you on Friday afternoon about his patient Christopher Walsh. He explains that Christopher is on levetiracetam 500 mg twice a day. He wants advice about the prescription your pharmacy supplied to Christopher last month.

“Christopher is concerned as he always gets his prescription from you, and every time he has received a large peach-coloured tablet. Last time he picked up his medicines his tablet was smaller and white in colour. This is causing him to be more anxious, and I am worried this could bring on a seizure.”

Construct a response to Dr Jones using the words you would use in this scenario.

The bottom line

You should inform the GP that you will look into what has happened and get back to him as soon as possible.

Why?

It is unlikely you would be able to answer the GPs questions over the phone without some further investigation. You should spend time gathering the information and then call the GP back at an appropriate time, to be able to answer his questions fully and determine exactly what has happened with the dispensing of Christopher’s prescription.


n Differences in the bioavailability between products can be an issue for some AEDs leading to adverse drug rections or an alteration in the therapeutic efficacy of the medicine.

n Different forms can cause confusion, which can lead to anxiety and a lack of adherence to the prescribed regimen. This has an overall impact on seizure control. Ideally patients should be given the exact same medicine at the time of dispensing5.

n The MHRA has classified AEDs into three categories depending on the potential for the differences in bioavailability to be clinically significant. For more information regarding these categories, visit the MHRA section on the Epilepsy Society website: www.epilepsysociety.org.uk/mhra-guidance-anti-epileptic-drugs



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n The pharmacy professional should ask to see the medicines supply so that they can establish what brand or generic medicine Christopher has received. There is also a possibility that this is a dispensing error.

n When the brand or generic medicine that Christopher normally receives has been established this should be noted on his patient medication record (PMR) to ensure this doesn’t happen again.


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References1. National Institute for Health and Care Excellence quality standard 26. Epilepsy in adults.

2013.

www.nice.org.uk/guidance/qs26

2. Great Ormond Street Hospital for Children. Buccal (oromucosal) midazolam. 2014.

www.gosh.nhs.uk/medical-information-0/medicines-information/buccal-

oromucosal-midazolam

3. Legislation.gov.uk. Mental Capacity Act 2005. No date.

www.legislation.gov.uk/ukpga/2005/9/contents

4. National Institute for Health and Care Excellence clinical guideline 137. Epilepsies: diagnosis

and management. 2012.

www.nice.org.uk/guidance/cg137

5. Gov.uk. Antiepileptic drugs: new advice on switching between different manufacturers’ products

for a particular drug. 2013.

www.gov.uk/drug-safety-update/antiepileptic-drugs-new-advice-on-switching-

between-different-manufacturers-products-for-a-particular-drug


https://www.gov.uk/drug-safety-update/antiepileptic-drugs-new-advice-on-switching-between-different-manufacturers-products-for-a-particular-drug

Notes


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Contacting CPPEFor information on your orders or bookings, or any general enquiries, please contact us by email, telephone or post. A member of our customer services team will be happy to help you with your enquiry.

Email [email protected]

Telephone 0161 778 4000

By post Centre for Pharmacy Postgraduate Education (CPPE)Manchester Pharmacy School1st Floor, Stopford BuildingThe University of ManchesterOxford RoadManchester M13 9PT

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Epilepsy - CPPE · 2016-08-30 · Epilepsy – ook 2 2 5 About your focal point event Before coming...

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Transcript of Epilepsy - CPPE · 2016-08-30 · Epilepsy – ook 2 2 5 About your focal point event Before coming...