A patient is on carbamazepine for his new onset seizures. He has now had 3 attacks in last 2 weeks. His serum level of carbamazepine is within the therapeutic range.
What is the next step in management?
Correct Answer B:
This patient has already been diagnosed with a seizure disorder. He has been placed on carbamazepine and is currently at a therapeutic level. But his seizures are not controlled. At this time another medication should be added. Choices include phenytoin and valproic acid.
> A repeat CT and EEG is not needed at this time.
> His carbamazepine level is therapeutic yet he still has seizures so obtaining a repeat level is not correct.
> Although lab tests may be necessary, it is not the best choice at this time.
Of the following, which is the most frequent cause of seizures in the elderly?
The conditions listed are all causes of seizures. Of course, there are many other causes of seizures in the elderly, including primary and metastatic neoplasias (e.g., electrolyte disorders). However, in the geriatric population, cerebrovascular disease is the most common cause of seizures, with about 10% of stroke victims developing epileptic seizures. Seizures are more common following hemorrhagic strokes compared to nonhemorrhagic strokes.
A 36-year-old male with a history of a seizure disorder is brought to the emergency department with generalized tonic-clonic activity. Emergency medical personnel report this has been ongoing for 20 minutes.
After initial resuscitative measures, the preferred medication in this situation is:
Correct Answer D: This patient presents in status epilepticus (SE). Although diazepam has long been an effective treatment, lorazepam has emerged as the preferred agent because of pharmacologic properties that should give it a longer duration of action than diazepam.
→ Phenytoin and fosphenytoin are limited by potentially serious adverse effects, such as hypotension.
→ Intravenous valproic acid has been shown in a pilot study to be equal to or better than phenytoin in aborting generalized SE, and it has been used in some cases of focal status epilepticus.
→ In some settings where drug intoxication might be likely, consider also adding naloxone.
Note: Suspect subtle status epilepticus or transformed status epilepticus in any patient who does not have improving level of consciousness within 20-30 minutes of cessation of generalized seizure activity.
A 52-year-old male with a history of seizure attacks suffered from loss of consciousness and tonic-clonic muscular contractions. His tongue fell back into his throat and he choked.
What is the medication of choice for the treatment of this patient's condition?
Valproic acid is considered the agent of first choice for the treatment of grandmal (tonic-clonic) seizures. It increases the levels of GABA by affecting the potassium channels and also creates direct membrane stabilizing effect. Since it acts through GABA it is the best medication for grandmal seizures with fewer side effects. It is administered orally with a dose of 1000-3000 mg in divided doses. Medication should be taken with food to reduce the GI upset.
→ Phenytoin (choice A), followed by topiramate, carbamazepine (choice E), and zonisamide are suitable alternatives.
→ Tiagabine (choice C) is a weak medication for the treatment of grandmal seizure and it is effective for the treatment of petitmal seizures.
→ Phenobarbital (choice D) is also not the choice of medication for grandmal seizure but it is a good choice for status epilepticus.
A 68-year-old man with a history of urolithiasis, suffered from a seizure attack which involved loss of consciousness with tonic and clonic muscular contractions. His tongue fell back into his throat and he choked.
Which of the following medications is contraindicated in this patient's treatment?
Correct Answer C:
This patient suffers from tonic-clonic seizures (formerly known as grand mal seizures), which is characterized by sudden loss of the consciousness followed by tonic and clonic muscular contractions.
Patients with a history of kidney stones or those taking high-dose vitamin C or calcium supplementation should not take Topiramate because of the increased risk of kidney stones.
→ Valproic acid is considered the agent of first choice for the treatment of grandmal (tonic-clonic) seizures.
→ Phenytoin and carbamazepine are reasonable second options among the older group of medications, but the newer medications tend to work equally well if not better and have better side effect profiles, especially long-term side effect.
→ Levetiracetam is indicated for primary generalized tonic-clonic seizures in adults and children aged 6 years or older, as well as for use in juvenile myoclonic epilepsy and for partial seizures.
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