Antiepileptic Medication Management

Introduction to Antiepileptic Medications

Newer antiepileptic medications, such as levetiracetam and lamotrigine, have fewer drug interactions and better side effect profiles, according to the American Academy of Neurology 1

Ensuring patient safety by minimizing the risk of injury, helping the person to lie down on the floor if necessary, and staying with the person during the seizure is recommended by the American Heart Association (AHA) 2
The AHA advises against restraining the patient or placing anything in their mouth during a seizure, and recommends not giving food, liquids, or oral medicines during a seizure 2
Seizure management involves identifying and treating underlying causes, including hypoglycemia, hyponatremia, drug toxicity, CNS or systemic infections, ischemic stroke or intracranial hemorrhage, and withdrawal syndromes, as recommended by the AHA and American College of Emergency Physicians 2, 3

First-line treatment for active seizures is benzodiazepines, followed by levetiracetam, fosphenytoin, or valproate as equally effective second-line options if seizures persist, according to the AHA and American College of Emergency Physicians 4, 5, 2
Valproate has been shown to have 88% efficacy in treating status epilepticus, with less hypotension compared to other options, according to the American College of Emergency Physicians 3
Fosphenytoin has a 56% efficacy rate, but carries a higher risk of hypotension, as reported by the American College of Emergency Physicians 3
Propofol can be used as an anesthetic agent, with a recommended dose of 2 mg/kg IV bolus, followed by 5 mg/kg/hr infusion, as suggested by the American College of Emergency Physicians 3

A comprehensive diagnostic workup for first-time seizures in children and adults is recommended, including imaging modalities, electroencephalography (EEG), laboratory tests, and antiepileptic drug levels, to identify underlying causes and guide treatment, as suggested by the American College of Radiology, AHA, and other guideline societies 5, 6, 3, 4, 7

Essential laboratory tests include:

Laboratory Test	Indication
Serum glucose	All patients
Serum sodium	All patients
Pregnancy test	Women of childbearing age
Complete metabolic panel	Altered mental status
Toxicology screen	Altered mental status, suspected substance use
CBC, blood cultures, lumbar puncture	Fever
Antiepileptic drug levels	Patients on seizure medications
CK levels	Generalized tonic-clonic seizure
Troponin levels	Older patients with generalized tonic-clonic seizure

MRI is the preferred imaging modality for first-time seizures in children and adults, as it is more sensitive than CT for detecting brain abnormalities, according to the American College of Radiology and American Academy of Neurology 8, 4, 7
EEG should be performed in all patients with first-time seizures to help differentiate seizure types and identify epilepsy syndromes, and should be performed within 24-48 hours of the seizure when possible, according to the American College of Radiology and American Academy of Neurology 8, 4

Patients can be discharged if they have returned to baseline mental status, had a single self-limited seizure with no recurrence, have normal or non-acute findings on neuroimaging, have reliable follow-up available, and have a responsible adult to observe the patient, with a strength of evidence level B, as recommended by the American College of Emergency Physicians 6, 3, 4
Discharge instructions should include seizure precautions and safety measures, driving restrictions according to local laws, medication instructions if prescribed, arrangement for follow-up with neurology, and advice on seizure triggers to avoid, as recommended by the American College of Emergency Physicians 6, 4
Referral to neurology is essential, as recommended by the American College of Radiology, and the neurological evaluation should include EEG to identify epilepsy syndromes and predict recurrence risk, classification of seizure type to identify the region of brain where seizure originated, and classification of epilepsy syndrome when possible, with a strength of evidence level B 7

Seizures lasting more than 5 minutes represent status epilepticus and require emergency medical intervention, according to the AHA and American College of Emergency Physicians guidelines 2
For status epilepticus, IV benzodiazepines are recommended, with lorazepam preferred over diazepam if available, and if seizures continue, IV phenobarbital or phenytoin may be used, as suggested by the AHA 9
Continuous EEG monitoring is crucial for detecting non-convulsive seizures and evaluating treatment response, as stated in the Journal of Neurology, Neurosurgery and Psychiatry 10
Transfer to ICU with continuous EEG monitoring is essential for patients with refractory status epilepticus, and consideration of anesthetic agents such as midazolam, propofol, or ketamine may be necessary, according to the Neurocritical Care Society 3
Mortality rates for status epilepticus range from 5-22%, increasing to 65% in cases refractory to first-line therapies, as reported in the literature 6

The American Academy of Neurology recommends relaxation training for patients with seizures 9
The American Academy of Neurology suggests considering cognitive-behavioral therapy for patients with depressive symptoms, medically unexplained somatic complaints, or those in distress, with a strength of evidence level C 9