Modern management of epilepsy: A practical approach (Ketogenic diet)

        The ketogenic diet is a very low carbohydrate, adequate-protein, high-fat diet used to treat refractory epilepsysince the 1920s. It requires a devoted multidisciplinary approach, which includes physicians,nurses, social workers, dieticians, and parents. The diet mimics the biochemical changes associated with starvation,which create ketosis. Although less commonly used in later decades because of the increased availability of anticonvulsants, the ketogenic diet has reemerged as a therapeutic option if AEDs fail to control seizures and surgery is not an option. The ketogenic diet should be continued for 1 or 2 years, if effective. It should be considered as alternative therapy for children with refractory epilepsy. Only a decade ago, the ketogenic diet was considered a last resort. Although no randomized controlled trials have been performed, large observational studies, some prospective, suggest an effect on seizures. These effects require validation in randomized controlled trials. It has become more commonly used in academic centers throughout the world. The Atkins diet is a recently used, less restrictive therapy that also creates ketosis and may be able to reduce the number of seizures. Dietary therapies may become even more valuable in the therapy of epilepsy when the mechanisms underlying their success are better understood. Although the ketogenic diet has been shown to be useful in the treatment of childhood epilepsy, the long-term effects of the ketogenic diet on nutritional status and brain development are not clear. Bicarbonate levels should be monitored carefully in patients treated with both topiramate and the ketogenic diet, and bicarbonate supplements given when symptomatic. Excessive bruising is a symptom noted by parents of some children treated with the ketogenic diet.Patients on the diet undergoing anticoagulation or surgery should be evaluated carefully for symptoms of bleeding tendency. The ketogenic diet may be associated with nephrolithiasis in some patients. The effect of the ketogenic diet on seizures requires validation in randomized controlled trials. For those with a difficult-to-treat epilepsy on multiple antiepileptic drugs, the ketogenic diet is a possible option

Recommendation.

The ketogenic diet is an option for drug-resistant epilepsy, particularly in children, when better proven treatments such as resective surgery and vagus nerve stimulation are not possible.