Dear Dr. Roach: My 22-year-old granddaughter had her first seizure less than a year ago. She had a few tests done, which showed that everything looked normal. She did an MRI, a CT scan and two electroencephalograms (EEGs). She was told that the seizures she had are non-epileptic ones and are much safer than epileptic ones.
She was put on Keppra, but she didn’t like the side effects of it. It made her feel loopy, tired and weak. Her doctor switched her to lacosamide twice a day. Side effects of this drug are similar. She’s had double vision and drowsiness, and she can no longer drive, which causes problems for her with getting to her job.
What are your thoughts on these drugs? She talks about discontinuing the medication. Can you suggest a different drug without as many side effects that could help her? Is there a different solution to her issue?
C.G.
An epileptic seizure is caused by uncontrolled electrical activity in the cerebral cortex. Seizures are common, with 8% to 10% of people having one in their lifetime. Not all seizures need to be treated, and the decision on whom to treat is sometimes complicated. But most people with recurrent seizures (i.e., epilepsy) are generally treated with anti-seizure medicines, such as lacosamide or Keppra. As your granddaughter has found, seizure medicines sometimes have significant side effects.
Psychogenic non-epileptic seizures (PNES) are involuntary responses to triggers such as emotional stress and menstruation, and can occur especially upon awakening. They do not have the abnormal electrical activity of a seizure and are not treated with anti-seizure drugs. However, they can look very similar to an epileptic seizure or may resemble a faint.
If the diagnosis on PNES is certain (which usually requires a video EEG during a seizure), then seizure medicines are slowly withdrawn, as they are unhelpful for PNES. The most effective treatments for PNES include eye movement desensitization as well as reprocessing therapy and cognitive behavioral therapy. Medication is not a standard way to treat PNES.
It’s very important to recognize that non-epileptic seizures are not under someone’s conscious control, but treatment can help people control them. It is true that people with PNES may have high levels of anxiety, but people with PNES are not “crazy” or “insane.” PNES may often be a response to psychological trauma.
More information about PNES can be found at tinyurl.com/PNESinfo.
Dear Dr. Roach: I have osteoarthritis in my thumb. I have now had two steroid injections six months apart. The injections provided great relief. Your recent column stated that regular steroid injections can damage the cartilage. How often is regular? My doctor has not advised me of the damage that injections can cause. Tylenol gave me little relief. Do you suggest I stop all steroid injections?
M.W.
In the studies that evaluated steroid injections compared to a placebo injections (both also included an anesthetic agent), most found that steroid injections every three months led to radiologically proven loss of cartilage by two years. I can’t answer which level is safe, but I do feel comfortable doing an injection every 12 months in patients who benefit from it. Every six months might be OK, but without data, I can’t say.
The data come mostly from knee injections, and it’s not clear that thumb cartilage will react the same way. In these cases, the clinical judgment of your doctor is really the key to balancing the risk and benefit.
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