Antiepileptics Audit - nwcscnsenate.nhs.uk · carbamazepine and phenytoin which reduce the steroid effect. The metabolism of phenytoin can be either increased or decreased by dexamethasone

Antiepileptics Audit Dr Kate Marley

Dr Lucy Potter

Dr Melanie Brooks

Dr Averil Fountain

CNS Sue Croft

External Reviewer: Dr A Nicolson

Consultant Neurologist

c

CURRENT GUIDANCE

4.1 GENERAL PRINCIPLES

• Anti-epileptic drugs should be considered in all patients with

primary or secondary brain tumours who have a history of one

or more seizures.

• The acute management of seizures includes maintaining the

airway, emergency drug treatment and a reassessment of the

anti-epileptic drugs prescribed.

• A prolonged seizure in a patient who is not in the

terminal phase requires immediate emergency management,

resuscitation and possible admission to hospital.


• A clear distinction should be made between anti-epileptic

drugs for the control of seizures and corticosteroid medication

for control of symptoms due to tumour oedema e.g. headaches

/ vomiting due to raised intracranial pressure or focal

neurological signs.

• Increasing the dose of corticosteroid is not recommended for

seizures in the absence of new neurological symptoms / signs

or evidence of raised intracranial pressure. However, as

seizures may increase cerebral oedema, patients who develop

new seizures in spite of anti-epileptic drugs may need

optimization of anti-oedema therapies before modifying anti-

epileptic drugs.


• In the terminal phase, the aim is to prevent and control

seizures with the minimum of disruption for the patient.

Midazolam or clonazepam may be given without the need

for transfer to hospital.

• Corticosteroids can be discontinued in the terminal

phase unless they are required for control of raised

intra-cranial pressure e.g. headaches/vomiting or

seizures.

Table 4.1 illustrates the World Health Organisation classification

of seizures

Table 4.1 International Classification of Seizures [Level 4]

1. Generalised (involving the entire

cortex).

Tonic-clonic seizures (grand mal).

Absence seizures (petit mal).

Myoclonic seizures.

Atonic seizures.

2. Partial/focal (involves a localised

area of

brain).

Note: May spread to involve the

whole cortex i.e. secondary

generalisation.

Simple (no effect on conscious level).

Complex (interrupt consciousness to

varying degree).

Secondary generalised tonic-clonic

seizures. c

Guidelines

• 4.2.1 Antiepileptic medication

– The ideal drug for controlling seizures in

palliative care patients is not easy to establish

due to the variety of metabolic interactions and

potential side effects. [Level 4]

– There are a variety of anti-epileptic drugs

available and Table 4.2 gives further details.

The choice of drug will depend on the type of

seizure. [Level 4]

• Clinical assessment should be used to optimise the dose of the

anti-epileptic drug with the minimum of side effects.

Monotherapy should be used whenever possible. [Level 4]

• It has been considered appropriate to use only new anti-

epileptic drugs when the older drugs (e.g. carbamazepine,

sodium valproate) have been unsuccessful, or where they are

unsuitable due to contraindications or drug interactions.

However, lamotrigine or carbamazepine are now considered

first line therapy for partial onset epilepsy, and lamotrigine has

the advantage of being better tolerated with few drug

interactions. [Level 4]

Guidelines

• Clobazam and clonazepam can be used for myoclonic or

generalised tonic-clonic seizures.

• They will be effective for short-term use but patients

may develop tolerance to the anti-epileptic effects of

the benzodiazepines. In addition, any benefit may

diminish over time although this may not always be

relevant in the palliative care setting. Despite the

possibility of tolerance with benzodiazepines many

patients do get a sustained response to drugs such as

Clobazam. [Level 4]

• The metabolism of dexamethasone is accelerated by

carbamazepine and phenytoin which reduce the steroid

effect. The metabolism of phenytoin can be either

increased or decreased by dexamethasone so altering the

anti-epileptic effect. When using these drug

combinations it may be necessary to increase the dose of

anti-epileptic and / or corticosteroid. Drug levels are

useful for patients on phenytoin. Levels can be used to

guide dose titration if seizures are poorly controlled or

side effects become apparent. [Level 3]

4.2.2 Management of seizures

• An acute seizure may settle spontaneously. Intranasal, buccal or

subcutaneous midazolam should be available for the control of

prolonged or recurrent seizures. Alternatively, lorazepam 2mg-4mg

can be given intravenously or subcutaneously. [Level 4] For more

information on intranasal midazolam see Figure 4.1.

• If seizures continue despite above measures, consider transfer to

hospital for emergency management. A secure airway should be

established, oxygen should be administered, cardio- respiratory

function should be assessed and intravenous access should be

established. Administer diazepam 10mg-20mg rectally and repeat 15

min later if status continues to threaten. Alternatively, consider

giving midazolam 10mg via the buccal route or intravenously.[Level 4]

Guidelines

• Clusters of seizures (i.e. with recovery in

between attacks) may respond to oral

clobazam.

• Starting dose is 10mg per day and the usual

maintenance dose is 10mg-20mg twice daily.

The maximum dose is 30mg twice daily. This

drug can be used for a short period if

required e.g.. a few days. [Level 4]

4.2.3 Use of anti-epileptics in the terminal phase

• In the terminal phase convert oral anti-epileptics to a

continuous subcutaneous infusion of midazolam 30mg-

60mg/24 hours. Clonazepam is an alternative and will

require less volume. [Level 4]

• If seizures are not controlled with midazolam / clonazepam,

consider a change to phenobarbital 200mg-600mg/24h via a

continuous subcutaneous infusion. Phenobarbital can be

mixed with sodium chloride 0.9% or water, although

anecdotal evidence suggests that may get less site reactions

with sodium chloride 0.9%. It is generally recommended that

a separate syringe driver should be used because of the high

pH of the drug. [Level 4] c


• Discontinue oral corticosteroids unless

needed for control of symptoms due to raised

intracranial pressure e.g.. headaches,

vomiting, seizures. Dexamethasone may be

administered by subcutaneous bolus injection

(for doses <8mg daily) or by a CSCI. [Level 4]

Standards

1. For all patients with primary or secondary

brain tumours, the following information

should be documented in the case notes: 14

[Grade D]

– History of seizures including the frequency and

type.

– Anti-epileptic drug(s) used and the dose(s).

Standards

2. The dose of corticosteroids should not be increased if

seizures occur in the absence of new neurological symptoms

/ signs or evidence of raised intracranial pressure, unless

the patient is also taking phenytoin or carbamazepine.

[Grade D]

3. All patients with a history of seizures should have access

to medication that can be given in the event of an episode

of prolonged seizures. [Grade D]

Standards

4. If a patient is in the terminal phase, oral anti-epileptic

drugs should be converted to midazolam / clonazepam via a

continuous subcutaneous infusion. [(Grade D]

5. If a patient is in the terminal phase and unable to take

oral medication, corticosteroids should be discontinued

unless they are needed for control of symptoms related to

raised intracranial pressure. If they are required, they can

be given via the subcutaneous route. [Grade D]

LITERATURE REVIEW

Before we start

• AED= NOT By definition, all patients

with brain tumour

associated epilepsy suffer

from PARTIAL-ONSET

seizures

Anti-epileptic drugs: a guide for the non-neurologist

• Choice of Anti-epileptic drug (AED) is complex:

– Age

– Co-morbidity

– Other medication

– Possibility of pregnancy

– Patient’s epilepsy classification

• When patients are nil by mouth:

• Try to use iv preparation where possible or NGT

• Beware Phenytoin suspension 90mg = 100mg tablet

Anderson J; Moor C: Clinical Medicine: Vol 10, Number 1, February 2010 , pp. 54-58(5)

Anti-epileptic drugs: a guide for the non-neurologist

• Routine checking of AED levels not needed

• Consider when:

– 1 week following change of phenytoin dose

– Status epilepticus

– Following emergency initiation of iv phenytoin

• Beware of enzyme inducing drugs and interactions:

– May decrease levels of warfarin and digoxin

– Many antidepressants lower seizure threshold

– Antipsychotics antagonise many AEDs

– Erythromycin/clarithromycin may increase levels of some AEDs

• In the elderly may need to choose drugs with fewer side effects rather

than most efficacious

Anderson J; Moor C: Clinical Medicine: Vol 10, Number 1, February 2010 , pp. 54-58(5)

SANAD Study (Arm A) • Aim was to assess efficacy of other drugs for partial onset

seizures where carbamazepine would have been considered

standard treatment

• Un-blinded RCT in hospital OPDs in UK

• Arm A 1721 pts. randomised to carbamazepine, lamotrigine,

oxcarbazepine, or topiramate.

• Primary outcomes: time to treatment failure and time to 12

months remission

• Results: Lamotrigine sig better than carbamazepine for time to

treatment failure outcomes and is a cost-effective alternative

for partial onset seizures

Marson AG, Al-Kharusi AM, Alwaidh M, Appleton R, Baker GA, Chadwick DW. SANAD study of

effectiveness of valproate, lamotrigine and topiramate for generalised and unclassifiable epilepsy:

an un-blinded randomised controlled trial. Lancet 2007; 369: 1016-1026

NICE Guidance

• Offer carbamazepine or lamotrigine as first-line treatment to

children, young people and adults with newly diagnosed focal

seizures. [new 2012]

• Combination therapy (adjunctive or 'add-on' therapy) should only

be considered when attempts at monotherapy with AEDs have not

resulted in seizure freedom.

• If an AED has failed because of adverse effects or continued

seizures, a second drug should be started (which may be an

alternative first-line or second-line drug) and built up to an

adequate or maximum tolerated dose and then the first drug

should be tapered off slowly

National Institute for Health and Clinical Excellence. Clinical guideline 137. NICE,

2012.

NICE Guidance

• Regular blood test monitoring in adults is not recommended

as routine, and should be done only if clinically indicated

• Indications for monitoring of AED blood levels are:

– detection of non-adherence to the prescribed medication

– suspected toxicity

– adjustment of phenytoin dose

– management of pharmacokinetic interactions (for example, changes

in bioavailability, changes in elimination, and co-medication with

interacting drugs)

– specific clinical conditions, for example, status epilepticus, organ

failure and certain situations in pregnancy


2012.

NICE Guidance: Management of a Seizure in the

Community • Only prescribe buccal midazolam or rectal diazepam for use in

the community for children, young people and adults who have

had a previous episode of prolonged or serial convulsive

seizures. [new 2012]

• Administer buccal midazolam as first-line treatment in

children, young people and adults with prolonged or repeated

seizures in the community. Administer rectal diazepam if

preferred or if buccal midazolam is not available. If

intravenous access is already established and resuscitation

facilities are available, administer intravenous lorazepam


2012.

SPECIFIC GUIDANCE FOR BRAIN

TUMOURS

Seizure Prophylaxis in Brain Metastases

• Systematic review of studies on patients with

brain metastases comparing anticonvulsant

prophylaxis versus none

• Only 1 underpowered RCT

• Conclusion: there is a lack of clear and robust

benefit from the routine prophylactic use of

anticonvulsants

Mikkelson T et al. The role of prophylactic anticonvulsants in the management of brain

metastases: a systematic review and evidence-based clinical practice guideline. Journal of

Neuro-Oncology January 2010, Volume 96, Issue 1, pp. 97-102

Cochrane Review of Seizure Prophylaxis in Brain

Tumours • 5 trials met inclusion criteria

• Different brain tumours with different seizure risks

• Phenobarbital, phenytoin and divalproex sodium did not

prevent seizures in people with brain tumours who had

been seizure-free before participation in the study

• No studies on the newer AEDs

• Clinical heterogeneity limits any claim of effectiveness

or ineffectiveness of prophylaxis

• Need to be mindful of the risks of side effects

Tremont-Lukats IW, Ratilal BO, Armstrong T, Gilbert MR. Antiepileptic drugs for preventing seizures

in people with brain tumors. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.:

CD004424.

SEIZURES IN PALLIATIVE CARE

CONTEXT

RAMPART Trial • Rapid Anticonvulsant Medication Prior to Arrival Trial

• Randomized double-blind phase 3 non-inferiority clinical trial

IM midazolam vs. IV lorazepam

• Children and adults requiring treatment for status epilepticus

in the pre-hospital setting

• Given either 10mg IM midazolam followed by IV placebo or IM

placebo followed by 4mg IV lorazepam

• Primary outcome termination of seizures prior to arrival at

A&E. Secondary outcomes time from opening box and time

from administration of meds to seizure termination

• Midazolam at least as effective as lorazepam (p<0.001)

Silbergleit R, Durkalsk V, Lowenstein D, Conwi R, Pancioli A, Palesch Y, Barsan W, Intramuscular

versus Intravenous Therapy for Prehospital Status Epilepticus. NEJM vol 366(7) 2012 591-600

Palliative Care Adult Network Guidelines

• Useful drugs in syringe driver :-

– clonazepam 1-4 mg/24h CSCI

– midazolam 20-100mg/24h CSCI

– phenobarbital 200-600mg/24h CSCI

• Avoid using drugs that may increase cerebral irritability

such as phenothiazines (e.g.. levomepromazine) if

possible.

• Should not be necessary to replace oral steroids with SC

in dying patients who are unconscious or semi-conscious

Watson M, Lucas C, Hoy A, Back I, Armstrong P. Palliative Care Adult Network

Guidelines 2011

Seizures At End of Life • No data regarding the preferred drug. In this Italian

paper IM phenobarbital was used in community pts. and

IV levetiracetam in hospitalised pts. at end of life [Pace

et al 2012]

• American paper: stop AED if pt. never had a seizure and

manage any seizures that occur. Aim to convert to

rectal preparation. Data on midazolam not available but

they say 5mg/hr [Hendrikus et al 2000]

Pace A, Andrea, Villani V, Di Lorenzo C, Guariglia L, Maschio M, Pompili A, Carapella C, Epilepsy in the end-of-life

phase in patients with high-grade gliomas. Journal of Neuro-Oncology Online first. Doi: 10.1007/s11060-012-0993-2

Hendrikus GJ, Krouwer MD, Jeanne L, Pallagi MD Graves NM. Management o seizures in Brain Tumor Patients at the

End of Life J Pall Med 2000 3(4) 465-475

Status Epilepticus in the Hospice Setting

• Problems specific to this setting:

– Cachexic frail patients with difficult iv access

– Not always appropriate to transfer to hospital

– Lack of monitoring facilities

– May need large doses of medications.

– May get toxicity from the medications

Droney J, Hall E. Status Epilepticus in a Hospice Inpatient Setting. J pain sympt

management 1 July 2008 (volume 36 issue 1 Pages 97-105)


• Benzodiazepines helpful as they enter cerebral

tissues quickly. Durations of action:

– Diazepam < 2 hours

– Midazolam 3-4 hours

– Clonazepam 24 hours

– Lorazepam up to 72 hours

• Clonazepam use may be limited by sorption to

driver giving set and precipitation Droney J, Hall E. Status Epilepticus in a Hospice Inpatient Setting. J pain sympt



• In refractory cases:

– Switch to different benzodiazepine

– May need drugs from 2 classes e.g.. midazolam

and phenobarbitone

– May need to switch from SC to iv route

– May need to consider moving to acute setting

depending on situation

Droney J, Hall E. Status Epilepticus in a Hospice Inpatient Setting. J pain sympt


AUDIT RESULTS

PATIENT BASED SURVEY

RESULTS

6

1

10

2

22

1

Title of Professional Completing Survey

Consultant

SAS

Registrar

CMT/VTS Doctor

CNS

Nurse

26%

31%

43%

Setting

Community

Hospice

Hospital

0

2

4

6

8

10

12

Aintree Halton Isle of Man Liverpool Southport,Formby and

WestLancashire

St Helen's andKnowsley

West Cheshire Wirral

ICN

c

4 3

2 0 0

4 4

29

3 3

6

1

0

5

10

15

20

25

30

35

Rescue Medication to Treat Seizures

c

0

2

4

6

8

10

12

There was nosubstitute

medicationprescribed

Midazolam 10mgcsci

Midazolam 20mgcsci

Midazolam 30mgcsci

PRN midazolamsubcutaneously

Other

Patients who entered the Dying Phase

0

5

10

15

20

25

30

Was the seizure typedocumented in the

notes?

Was the seizurefrequency

documented in thenotes?

Patients Without Brain Tumours

NO

YES

0

5

10

15

20

25

30

Was the seizuretype documented in

the notes?

Was the seizurefrequency

documented in thenotes?

Patients With Brain Tumours

NO

YES

For Patients With Brain Tumours

• 17 patients had a

seizure during the

audit period

13

7

0

2

4

6

8

10

12

14

There was a changein neurology

There was evidenceof raised intracranial

pressure

Patients who had a seizure

0

2

4

6

8

10

12

14

16

18

Steroid dose changed Steroid dose Increased Steroid dose decreased

What happened to the steroid dose?

11

9

1

8

0

2

4

6

8

10

12

Anticonvulsant dosechanged

Anticonvulsant doseincreased

Anticonvulsant dosedecreased

New anticonvulsantdrug added

Anticonvulsant Use

24%

43%

5%

28%

Steroids in Dying Phase

The steroids were stopped

The steroids were convertedto SUBCUT stat injections nodose change

The steroids were convertedto SUBCUT stat injections andthe dose was decreased

The steroids were convertedto a csci at the same dose

PRACTICE BASED SURVEY

RESULTS

8

6 1

9

Role of People Completing Survey

Consultant

SAS doctor

Specialty Registrar

Clinical Nurse Specialist

10

4

3 3

4

0

2

4

6

8

10

12

Aintree Wirral Liverpool Halton Warrington

ICN

3

11

8

2

Predominant Setting of Work

Community

Hospice

Hospital

Across settings

0

15

1 0

5

0

2

4

6

8

10

12

14

16

On diagnosis After the first seizure After second seizure After 3rd seizure I would not normallyinitiate therapy

On diagnosis of brain mets I would start an anticonvulsant...

What anticonvulsant medication would you prescribe in

epilepsy related to cerebral metastases?

0

2

4

6

8

10

12

14

16

18

Third line

Second line

First line

1

11

3

6

0 0

2

4

6

8

10

12

Very Confident Confident Neither Not confident Not at all confident

Confidence in initiating anticonvulsants

0

9

3

9

0 0

1

2

3

4

5

6

7

8

9

10


Confidence in adjusting anticonvulsant dose

0

3

4

10

4

0

2

4

6

8

10

12


Confidence in adding in another anticonvulsant

1

4

5

8

3

1

5

4

8

3

0

2

5

10

4

0

2

4

6

8

10

12

Very Confident Confident Neither Not confident Not at allconfident

For patients with pre-existing epilepsy

Confidence initiatinganticonvulsant therapy

Confidence adjustinganticonvulsant dose

Confidence adding inanother anticonvulsant

0

2

4

6

8

10

12

14

16

Weekly Fortnightly Monthly On change indose

Steroid dosechange

Signs orsymptoms of

toxicity

If the renalfunctionchanges

If the liverfunctionchanges

I don'troutinely

check levels

When Phenytoin/Carbamazepine levels checked

1 2

17

3

1

6

1

0

2

4

6

8

10

12

14

16

18

Audit Guidelines Doctor Neurologist Palliative CareDoctor

Palliative CareTeam

Pharmacist Treating Doctor

From where advice is sought

0

2

4

6

8

10

12

14

16

18

Medications to manage a seizure

Partial Seizures

Generalized Seizures

Multiple seizures

0

8

4

2

0 0 0

5

0

1

2

3

4

5

6

7

8

9

Midazolam10mg csci

Midazolam20mg csci

Midazolam30mg csci

Midazolamother dose csci

Midazolam scprn only

Clonazepam csci Stopanticonvulsants

only

Other (pleasespecify)

Conversion of anticonvulsants in the dying phase

3

8

7

4

11

0

2

4

6

8

10

12

Stop Steroids Convert steroid doseto syringe driver

Convert steroid doseto sc injections

Reduce steroids to adaily sc dose

Other

Steroids in the dying phase

UPDATED STANDARDS AND

GUIDELINES


• Anti-epileptic drugs should be considered in all patients with

primary or secondary brain tumours who have a history of one

or more seizures.

• Patients with seizures due to brain tumours by definition have

partial-onset seizures.

• The acute management of seizures includes maintaining the

airway, emergency drug treatment and a reassessment of the

anti-epileptic drugs prescribed.

• A prolonged seizure in a patient who is not in the

terminal phase requires immediate emergency management,

resuscitation and possible admission to hospital.


• A clear distinction should be made between anti-epileptic

drugs for the control of seizures and corticosteroid medication

for control of symptoms due to tumour oedema e.g. headaches

/ vomiting due to raised intracranial pressure or focal

neurological signs.

• Increasing the dose of corticosteroid is not recommended for

seizures in the absence of new neurological symptoms / signs

or evidence of raised intracranial pressure. However, as

seizures may increase cerebral oedema, patients who develop

new seizures in spite of anti-epileptic drugs may need

optimization of anti-oedema therapies before modifying anti-

epileptic drugs.


• In the terminal phase, the aim is to prevent and control

seizures with the minimum of disruption for the patient.

Midazolam or clonazepam may be given without the need

for transfer to hospital.

• Corticosteroids can be discontinued in the terminal

phase unless they are required for control of raised

intra-cranial pressure e.g. headaches/vomiting or

seizures.

Table 4.1 illustrates the World Health Organisation classification

of seizures

Table 4.1 International Classification of Seizures [Level 4]

1. Generalised (involving the entire

cortex).

Tonic-clonic seizures (grand mal).

Absence seizures (petit mal).

Myoclonic seizures.

Atonic seizures.

2. Partial/focal (involves a localised

area of

brain).

Note: May spread to involve the

whole cortex i.e. secondary

generalisation.

Simple (no effect on conscious level).

Complex (interrupt consciousness to

varying degree).

Secondary generalised tonic-clonic

seizures. c

Guidelines

• 4.2.1 Antiepileptic medication

– The ideal drug for controlling seizures in

palliative care patients is not easy to establish

due to the variety of metabolic interactions and

potential side effects. [Level 4]

– There are a variety of anti-epileptic drugs

available and Table 4.2 gives further details.

The choice of drug will depend on the type of

seizure. [Level 4]

Guidelines

• Clinical assessment should be used to optimise the dose of the

anti-epileptic drug with the minimum of side effects.

Monotherapy should be used whenever possible. [Level 4]

• Lamotrigine or carbamazepine are now considered first line

therapy for partial onset epilepsy, and lamotrigine has the

advantage of being better tolerated with few drug

interactions. This means that Lamotrigine or Carbamazepine

will be the first choice foe seizures associated with brain

tumours [Level 4]

Guidelines

• For generalised-onset seizures sodium valproate should be

considered as the first line anti-epileptic medication.

• Routine, regular blood test monitoring of antiepileptic drug

levels is not recommended as and should be done only if

clinically indicated.

• Indications for monitoring of AED blood levels are: – suspected toxicity

– Poorly controlled seizures

– 1 week following adjustment of phenytoin dose

– management of pharmacokinetic interactions

– Status epilepticus

– Organ failure

Guidelines

• Clobazam and clonazepam can be used as an adjunct for

myoclonic or generalised tonic-clonic seizures.

• They will be effective for short-term use but patients

may develop tolerance to the anti-epileptic effects of

the benzodiazepines. In addition, any benefit may

diminish over time although this may not always be

relevant in the palliative care setting. Despite the

possibility of tolerance with benzodiazepines many

patients do get a sustained response to drugs such as

Clobazam. [Level 4]

• The metabolism of dexamethasone is accelerated by

carbamazepine and phenytoin which reduce the steroid effect.

• The metabolism of phenytoin can be either increased or

decreased by dexamethasone so altering the anti-epileptic

effect.

• When using these drug combinations it may be necessary to

increase the dose of anti-epileptic and / or corticosteroid. Drug

levels may be helpful in this situation. [Level 3]

4.2.2 Management of seizures

• An acute seizure may settle spontaneously. Intranasal, buccal or

subcutaneous midazolam should be available for the control of

prolonged or recurrent seizures. Alternatively, lorazepam 2mg-4mg

can be given intravenously or subcutaneously. [Level 4] For more

information on intranasal midazolam see Figure 4.1.

• If seizures continue despite above measures, consider transfer to

hospital for emergency management. A secure airway should be

established, oxygen should be administered, cardio- respiratory

function should be assessed and intravenous access should be

established. Administer diazepam 10mg-20mg rectally and repeat 15

min later if status continues to threaten. Alternatively, consider

giving midazolam 10mg via the buccal route or intravenously.[Level 4]

Guidelines

• Clusters of seizures (i.e. with recovery in

between attacks) may respond to oral

clobazam.

• Starting dose is 10mg per day and the usual

maintenance dose is 10mg-20mg twice daily.

The maximum dose is 30mg twice daily. This

drug can be used for a short period if

required e.g. a few days. [Level 4]


• In the terminal phase convert oral anti-epileptics to a

continuous subcutaneous infusion of midazolam 20mg-

60mg/24 hours. Clonazepam is an alternative and will

require less volume. [Level 4]

• If seizures are not controlled with midazolam / clonazepam,

consider a change to phenobarbital 200mg-600mg/24h via a

continuous subcutaneous infusion.

– Phenobarbital can be mixed with sodium chloride 0.9% or water,

although anecdotal evidence suggests that may get less site

reactions with sodium chloride 0.9%.

– It is generally recommended that a separate syringe driver should

be used because of the high pH of the drug. [Level 4]


• For patients with brain tumours:

– Discontinue oral corticosteroids unless needed

for control of symptoms due to raised

intracranial pressure e.g. headaches, vomiting,

seizures.

– Dexamethasone may be administered by

subcutaneous bolus injection (for doses ≤8mg

daily) or by a CSCI. [Level 4]

Patient has seizure

Ensure airway secure and administer oxygen if available

If seizure does not settle within 5 minutes give rescue medication e.g. Buccal or IM midazolam 10mg or rectal diazepam 10-20mg or lorazepam

2-4mg iv or sub cut

If seizure does not settle after 15mins give another dose of rescue medication. Consider transfer to

hospital

If patient to stay in hospice or at home consider a syringe driver with midazolam 30mg over 24

hours

Seizure may settle spontaneously

Standards

1. For all patients with primary or secondary brain

tumours, any history of seizures should be

documented in the case notes: [Grade D]

2. For all patients with a history of seizures the

following should be documented:

– Frequency and type of seizure

– Anti-epileptic drug(s) used and the dose(s) [Grade D]

– .

Standards

3. All patients with a history of seizures should have access

to medication that can be given in the event of an episode

of prolonged seizures. [Grade D]

4. For patients with brain tumours the dose of

corticosteroids should not be increased if seizures occur in

the absence of new neurological symptoms / signs or

evidence of raised intracranial pressure, unless the patient

is also taking phenytoin or carbamazepine. [Grade D]

Standards

5. If a patient is in the terminal phase, oral anti-epileptic

drugs should be converted to midazolam or clonazepam via

a continuous subcutaneous infusion initially. [Grade D]

6. If a patient is in the terminal phase and unable to take

oral medication, corticosteroids should be discontinued

unless they are needed for control of symptoms related to

raised intracranial pressure. [Grade D]

Documents

Antiepileptics Audit - nwcscnsenate.nhs.uk · carbamazepine and phenytoin which reduce the steroid effect. The metabolism of phenytoin can be either increased or decreased by dexamethasone