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Having temporal lobe epilepsy. On different medication. Suggest some proper treatment

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Practicing since : 2003
Answered : 2189 Questions
     My wife XXXXXXX XXXXXXX is having Temporal lobe epilepsy since last 30 yrs. She is on the following drugs:
Eptoin          100     100     100mg
Tegritol      400     300     400mg
Recently we have introduced (since an year)     
Lacosam          -     -     50mg
She has tolerable body movements due to long term usage of the above
drugs and is managing her works except cooking.
     Recently she fell ill (malaria) for a few days as a result of
which her food intake got reduced, but was consuming epilleptic medicines.
As a consequence she developed acidity followed by vomiting and needed to
be hospitalized. Subsequent to treatment since the last one and half
month her medication is as follows:
Tegritol      400      300     400mg
Eptoin      100      100     100mg
Lacosam      50      -      50mg
clonotril(0.5mg     1     -     1(withdrawn since last few days)
Pacitane(2mg)     1/2     1/2     1/2
Recovon(25mg)     1/2     1/2     1/2
Consequent to the usage of these medicines since the last 1.5
months, her body is not stable and movements have increased. After
discussion with Doctor, he reduced Clonotril to one at night. As she is
aware of what is happening to her body she revolted on the other day and
refused to take medicines other than Eptoin, Tegritol, Lacosam and some
vitamin supplements.As a consequence I dropped Clonotril completely, as this was not
effective on earlier ocassions, at different times in her long treatment
history. I am continuing other tablets. Now her intake is :

Tegritol      400     300 400mg
Eptoin(100mg)     1     1     1
Lacosam(50mg)     1     -     1
Pacitane(2mg)     1/2     1/2     1/2
Recovon(25mg)     1/2     1/2     1/2
Her body movements continue, she cannot sit for long time and lies down which was not the case when she was using only epilleptic medicnes.
She is always better before before commencement of any dosage that is due
(for short duration only). After nearly one and half hours of dosage, her
ordeal starts.In the morning before first dosage she is absolutely normal.
Please give your suggestions.
Posted Fri, 16 Nov 2012 in Epilepsy
Answered by Dr. Jonas Sundarakumar 2 hours later
Welcome to Healthcare Magic and thanks for your query.

Now, there are broadly two groups of medication which you wife seems to have been prescribed:

1) Eptoin (Phenytoin), Tegretol (Carbamazepine) and Lacosam (Lacosamide) are anti-epileptic medications.
2) Pacitane (Trihexyphenidyl), Revocon (Tetrabenzine) and Clonotril (Clonazepam) are different medication (not anti-epileptics), which are prescribed for hyperkinetic movement disorders, like tardive dyskinesia, etc. Usually long term intake of certain anti-epileptic medication can result in dyskinesias. Now, the second group of medication has been introduced only since the last 1 1/2 months, which probably means that she could developed these dyskinetic symptoms recently, as a side effect of long-term use of anti-epileptic medication.

In order to understand her problems better, please provide the following clarifications:

- What are the abnormal movements she is having? Please describe the location, type and frequency of movements.
- How long has she been having these new movements?

- What are the usual symptoms of epilepsy that she gets?
- How long has she been free of the usual epilepsy symptoms?

Please get back to me with these details so that I will be able to guide you better.

- Dr. Jonas Sundarakumar
Consultant Neuro-Psychiatrist
Above answer was peer-reviewed by
Follow-up: Having temporal lobe epilepsy. On different medication. Suggest some proper treatment 25 hours later
Dear Dr XXXXXXX Sundarakumar,
Thanks for your response.Replies for queries as per their sequence.
a.Every part of body moves when awake.While in sleep fingers move(up and
b.When on walk it will not be straight but bit wayward.Need to be
slightly guided to prevent fall etc.While eating with spoon movement is
jerky and some time food spills.

2.How long
since the introduction of movement control medicines

Before epilepsy some times she gets smell.Fits are simple,no foaming.Some

times she is aware of seizure,moves around with out responding to

call,and some times (most of the time she slides from sitting position

in sofa,rolls over rolls and remains still in lying position). Some times when in

standing position if seizure occurs she falls and get injured.During one

of those times,her collar bone broke,rib broke,head injured.But

miraculously re recovers in shortest possible time.All these have not

affected our life and we are a happy lot.

4Frequency of Fits
Generally around full moon,and amavasya days with some variations.With

the introduction of movement disorder medicines frequency increased but

patient senses.

Hope I could answer your queries.

Please let me know the dosage of epileptic medicines and movement disorder

medicnes can be given at the same time or with some time

difference.Presently I keep a gap of 1 hr,as patient is not accepting

Recovon and Pacitane along with epileptic medicines.Clonotril is now with

drawn.Other two are mixed in milk and administered.

With present treatment after say 1-1.5** hrs of dosage, patient loses

mobility,i.e,cannot stand properly,walk,or sit.She lies down and returns

to normalacy say after 3-4 hrs.Patient is made to lye mostly to avoid

injury.All this after introduction of movement disorder medicnes,which

she is refusing to take as she knows her condition before illness and

subsequent treatment.

**at this moment she is active talking to relatives

Thanks and regards,

Answered by Dr. Jonas Sundarakumar 4 hours later
Hello again and thanks for the clarifications.

There seem to be two separate problems which your wife seems to be suffering from. One is the long-standing problem of epilepsy (characteristic of movement disorder.

This type of movement disorder occuring after many years of taking medication is called Tardive Dyskinesia. ('tardive' = means late; 'dyskinesia' = means abnormal movements). Like I had mentioned earlier, this tardive dyskinesia is unfortunately, a side effect of medication such as Tegretol and Eptoin.

My assumption is that the doctor must have noticed mild features of this tardive dyskinesia recently and that must have been the reason for starting the new medication like Clonotril, Recovon and Pacitane. Unfortunately, after staring this combination of medication, the movement disorder seems to have worsened.

Now, tardive dyskinesia is generally a difficult-to-treat condition and often success is variable and partial. The following approach is used in treating this condition:
1) The first step is decreasing the dosage of the causative medication to the lowest effective dosage (or) sometimes, in severe cases, even stopping that medication and replacing it with another medication

2) Other medication which have been reorted useful managing tardive dyskinesia are are Tertabenzine (Recovon), Dopaminergic medication like Bromocriptine, Benzodiazepines like Clonazepam, GABAergic medication, as well as other medication like Vitamin E, Propranol, Clonidine, etc.

Pacitane can have a variable effect on patients with tardive dyskinesia, sometimes causing worsening of symptoms.

So, in your wife's case, My recommendations would be:
1) To gradually reduce the dose of Tegretol and / or Phenytoin or replace it with some other anti-epileptic medication. (remember, this is the universally accepted and proven recommendation - reducing the dosage of the causative medication). In order to prevent any attacks of fits when reducing or stopping these medication, she can be put on some other anti-epileptic medication. GABAergic anti-epileptics would be a good choice as they act as an anti-epileptic as well as can be useful for the movement disorder.
2) My opinion is that Pacitane may be the culprit in worsening the movement disorder. I have seen this in happening in many patients. Moreover, you clearly mention that the movement disorder has worsened after introduction of the movement disorder medication. So, it would be advisable to gradually reduce and stop Pacitane.
3) Tertabenzine (Recovon) can be continued as it has been proven beneficial in many patients.
4) Other medication can be tried for the movement disorder like Vitamin E, Dopaminergic medication, etc.

So, please have a detailed discussion with her doctor about the medication change / alteration, so that further treatment options can be tried. When you know that she is clearly worsening with this combination of medication, it is unwise to simply keep continuing it and not take other active measures. If you feel necessary, you can take her to a neurologist for a second opinion regarding the medication alterations.

Best wishes,
Dr. Jonas Sundarakumar
Consultant Neuro-psychiatrist
Above answer was peer-reviewed by
Follow-up: Having temporal lobe epilepsy. On different medication. Suggest some proper treatment 1 hour later
Dear Dr.JonasSundarakumar,
Thanks for kind reply and the elaboration provided.Please confirm whether these movement disorder medicines can be given along with epilleptic.

Answered by Dr. Jonas Sundarakumar 9 hours later

Like I had mentioned earlier, the current movement disorder medication needs to be altered or changed, because it seems to be only worsening her problems. I would recommend that Pacitane can be gradually reduced and stopped. On the other hand, some other medicine can be tried for the movement disorder (which can be taken along with the anti-epileptic medication)

Dr. Jonas Sundarakumar
Consultant Neuro-psychiatrist
Above answer was peer-reviewed by
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