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School of Pharmacy
Clinical Pharmacy Unit
Status Epilepticus:
A seizure lasting > 5 minutes or recurrent seizures without recovery to baseline between episodes.
A. PATIENT ASSESSMENT
CURRENT MEDICAL CONDITIONS AND MEDICATIONS
Date:
INFORMATION
Name:
CONTACT
Address:
Tel. (w): Tel. (h): Cell:
Dosage Regimen
Medication dose, route, frequency, Start Date Stop Date Indication
Past Medication Therapy
duration
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MEDICAL HISTORY
Tobacco Alcohol
Caffeine Other
1. Take an adequate history to define the type of epilepsy. Is usually made clinically.
2. Although rare, juvenile myoclonic epilepsy and absence - Requires an accurate witness description of the seizure.
seizures should be specifically considered and identified, as Some different types of seizures:
some standard medications may be less efficacious in these Partial Simple partial Seizure on one
side of the body
conditions or may even worsen seizure frequency or severity. with no loss of
3. All patients with new onset epilepsy should have a CT scan consciousness
Complex partial Partial seizure
and other investigations as clinically indicated.
associated with
4. A single unprovoked seizure is usually not an indication for
loss of
treatment although 40% of patients may have a subsequent
consciousness.
seizure within 2 years. Generalised Generalised tonic - Loss of
5. Anticonvulsants should be commenced after a single Clonic consciousnes
s preceded
INVESTIGATIONS
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- Usually no
muscle
twitching.
- Some
children will
smack their
lips.
Pain Impotence
Constipation Seizure
Dirrhoea Stroke/TIA
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Endocrine Systems Diabetes Syphilis
Hypothyroidism Gonorrhea
Menopausal Symptoms Herpes
Hepatitis Tuberculosis
Nutrition/Fluid/ Dehydration
Electrolytes Edema
Potassium deficiency
VITAL SIGNS
STG: (2014)
General rule: a single medicine is best.
- Combination therapy should only be initiated by a specialist.
Recommended doses are general guides and will be effective in most patients.
Some patients may need much higher or lower doses. Doses should only be increased at 2-weekly intervals.
Therapeutic monitoring will assist with dosage adjustments, or in suspected non-adherence. However, it is only
mandatory in the case of higher than usual doses of phenytoin.
CURRENT MEDICATION (POST DIAGNOSIS)
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- Thereafter, increase by switched from efavirenz- or
50 mg every 2 weeks nevirapine-based ART to
according to response.
lopinavir/ritonavir-based
- Usual maintenance
dose: 100–200 mg/day ART because the metabolism of
as a single dose. lamotrigine is induced by
lopinavir/ritonavir.
Poorly controlled epilepsy
Ask about the following, as these factors can influence decisions regarding
medicine therapy:
- Has the patient been adherent in taking the medication regularly for at least 2 weeks or more before the seizure? Ask about
medicine dosage and frequency.
- Has the patient recently used some other medicine? (i.e. look for drug interactions).
- Is there a chance that alcohol is involved?
If ≥ 1 of the above are present, address the problem/s but leave anticonvulsant therapy unchanged (unless dose adjustment is
necessary because of a drug interaction). Reassess the patient within 2 weeks.
STG HOSPITAL GUIDELINES (2015)
MEDICINE TREATMENT
- The aim is to use monotherapy, i.e. a single anticonvulsant, progressively increasing the dose until the seizures are
controlled or clinically important side effects occur.
- If the initial medication fails to achieve satisfactory control with optimal dosages, or causes unacceptable adverse
effects, then a second medicine may be started.
- The first drug should be continued for 2 weeks and then gradually reduced over 6– 8 weeks until stopped. If the
second drug fails, and alcohol and poor adherence are excluded, then combination therapy may be required.
- Refer patients for specialist investigation.
- Patients with a history of myoclonic seizures or typical absence seizures should preferably be treated with valproate,
as those seizures may be aggravated by the use of either phenytoin or carbamazepine.
OR oral.
Lamotrigine, o 25 mg daily for 2 weeks,
then 50 mg daily for 2
weeks.
o Thereafter, increase by
50 mg every 2 weeks
according to
response.
o Usual maintenance dose:
100–200 mg daily as a
single dose.
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50 mg increments at
intervals no shorter than 2
weeks.
For patients not stabilised on or who do not tolerate the above medications:
Valproate, oral. Usual starting dose: 200–
o 300 mg 12 hourly.
o Increase, as required,
every 2 weeks to a
maximum daily dose of
1.2 g 12 hourly.
Other epilepsy types
Manage in consultation with a specialist.
Specifically, juvenile myoclonic epilepsy is best controlled with valproate
initially, and absence seizures with valproate or lamotrigine.
HIV-infected individuals on ARVs: Phenytoin, phenobarbital and carbamazepine are enzyme inducing antiepileptic
medicines. Due to potential drug interactions with antiretroviral
drugs, switch patients on these anti-epileptics to lamotrigine or valproate.
Lamotrigine, oral. Note: The metabolism of
o 25 mg daily for 2 weeks, lamotrigine is induced by
then 50 mg daily for 2 lopinavir/ritonavir and
weeks. atazanavir/ritonavir. The
o Thereafter, increase by dose of lamotrigine may
50 mg every 2 weeks need to be increased when
according to patients are switched to a
response. lopinavir/ritonavir- or
o Usual maintenance dose: atazanavir/ritonavir -
100–200 mg daily, as a containing regimen.
single dose or 12
hourly.
OR
Valproate, oral.
o Usual starting dose: 200–
300 mg 12 hourly.
o Increase, as required,
every 2 weeks to a
maximum dose of 1200
mg 12 hourly.
Add on therapy to valproate:
Lamotrigine , oral.
o Start with 25 mg daily on
alternate days for 2 weeks,
increasing to
25 mg daily for 2 weeks.
o Thereafter increase by
25–50 mg every 2 weeks
according to
response.
Pregnancy: Optimal control of epilepsy on a single agent is the best management. ( Do not initiate valproate during
pregnancy, as it is associated with a higher teratogenic potential than the other first line agents)
Before pregnancy is
considered, folate
supplementation:
Folic acid, oral, 5 mg daily.
o Pregnancy alters drug
levels, adjust dose according
to levels.
Prophylaxis in head trauma: Phenytoin may be of benefit during initial period following significant head trauma.
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administered not faster than
50 mg/minute preferably with
cardiac
monitoring.
o If arrhythmias occur,
interrupt the infusion
temporarily and
reintroduce slowly.
o Continue with, IV, 5
mg/kg/day (300 mg daily for
most adults).
STATUS EPILEPTICUS: Seizures should be stopped promptly as prolonged seizures can cause
permanent brain damage. Aim for definitive control within 60 minutes of onset.
INITIAL TREATMENT
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If seizures are controlled: IV/oral, 300 mg daily.
Phenytoin, o First maintenance dose
should be no more than 12
hours after the
loading dose.
B. THERAPEUTIC PLAN
INDICATION EFFECTIVENESS SAFETY COMPLIANCE
DRP-1: Unnecessary Drug DRP-3: Alternative Drug DRP-5: Adverse Drug Reaction DRP-7: Non-adherence
Therapy Therapy Undesirable effect Directions not
No medical indication More effective drug Unsafe drug for patient understood
Duplicate therapy available Drug interaction Patient prefers not to
Nondrug therapy Condition refractory to Dosage administered or take
indicated drug changed too rapidly Patient forgets to take
Treating avoidable ADR Dosage form Allergic reaction Patient cannot afford
Addictive/recreational inappropriate Contraindications present Cannot
DRP-2: Needs Additional Drug Not effective for DRP-6: Dosage too High swallow/administer
Therapy condition Wrong Dose Drug product not
Untreated condition DRP-4: Dosage too Low Frequency inappropriate available
Preventive/prophylactic Wrong dose Duration inappropriate DRP-8: Other
Synergistic/potentiating Frequency inappropriate Drug interaction
Drug interaction Incorrect administration
Duration inappropriate
Description of Drug Related Problem Therapeutic Alternatives (medicine, dose, duration)
1.
GOALS OF THERAPY
2.
3.
4.
5.
6.
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- Extensive health education.
- Record keeping in a seizure diary recording dates and, if possible, the times of the seizures.
- Present seizure diary at each consultation for assessment of therapy.
- Carry a disease identification bracelet, necklace or card.
- Counselling and advice on:
the adverse effect of alcohol on seizures,
the effect of missing a dose of medication,
NON-PHARMACOLOGICAL THERAPY & PAITENT EDUCATION
- Record dates and, if possible, times of seizures in a seizure diary. Present seizure diary at each consultation for
assessment of therapy.
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Date: Notes/Remarks
PROGRESS NOTES
D. LABORATORY RESULTS
HAEMATOLOGY
WCC 4 – 11 /L
RBC 3.8 – 4.8 /L
Haemoglobin (HB) 14 – 18 gm/L
Hematocrit 0.368 – 0.473 L/L
MCV 77.1 – 91.5 fl
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MCH 25.8 – 31.7 pg
Platelets 140 – 440 /L
CRP 0 – 10
INR 1.0 – 1.2
PTT 35 – 45 sec
Fibrinogen 1.8 – 3 g/L
PT 10 –12 sec
D-Dimer < 250
Iron Serum 10 – 30 umol/L
Ferritin 10 – 120 ug/L
Vit B12 200 – 1100
Folic Acid 2 – 15
ARTERIAL BLOOD GAS
PH 7.35 – 7.45
PO2 75 – 90 mm Hg
PCO2 35 – 45 mm Hg
Base Excess -2 to +2
HCO3 20 – 25 mmol/L
Oxygen sats 95 – 98 %
CEREBROSPINAL FLUID
Protein 0.1 - 0.45g/L
Glucose 2.5 – 5.5 mmol/L
Chloride 120 – 130 mmol/l
CSF - ADA < 6 u/L
CHEMISTRY
Na 135 – 147 mmol/L
K 3.5 – 5.3 mmol/L
Cl 95 – 105 mmol/L
Urea 2.6 – 7.0
Creatinine Mmol/L
Phosphates 0.80 – 1.60 mmol/L
Calcium 2.20 – 2.56 mmol/L
LIVER FUNCTION TEST
Total Protein 60 – 85 g/L
Albumien 40 – 60 g/L
Total Billirubin 3.42 – 25.7 umol/L
ALP 40 – 120 u/L
AST 5 – 40 u/L
ALT 5 – 40 u/L
GGT 0 – 60 u/L
Total Cholesterol 3.87 – 5.17 mmol/L
LDL <4.1 mmol/L
HDL >1.04 mmol/L
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