What is the management of breakthrough seizures?

From the Guidelines

Breakthrough seizures should be managed with a second-line agent such as fosphenytoin, levetiracetam, or valproate if they are refractory to appropriately dosed benzodiazepines. The management of breakthrough seizures is crucial to prevent further complications and improve patient outcomes. According to the most recent guidelines, fosphenytoin, levetiracetam, or valproate may be used with similar efficacy as second-line agents 1.

When managing breakthrough seizures, it is essential to consider the patient's individual needs and medical history. The choice of second-line agent should be based on the patient's specific condition and the potential side effects of the medication. For example, levetiracetam may be a preferred option due to its relatively favorable side effect profile 1.

In addition to second-line agents, benzodiazepines such as lorazepam or midazolam may be used as first-line treatments for breakthrough seizures. However, if the seizure is refractory to benzodiazepines, a second-line agent should be administered promptly 1.

It is also important to note that regular antiepileptic medication adherence remains the cornerstone of preventing breakthrough seizures. Patients with epilepsy should have a seizure action plan that includes rescue medication instructions, and caregivers should be trained in proper administration techniques.

Overall, the management of breakthrough seizures requires a comprehensive approach that takes into account the patient's individual needs and medical history. By using second-line agents such as fosphenytoin, levetiracetam, or valproate, and prioritizing regular antiepileptic medication adherence, healthcare providers can improve patient outcomes and reduce the risk of further complications 1.

Some key points to consider when managing breakthrough seizures include:

• Administering a second-line agent if the seizure is refractory to benzodiazepines 1
• Choosing a second-line agent based on the patient's individual needs and medical history 1
• Prioritizing regular antiepileptic medication adherence to prevent breakthrough seizures 1
• Having a seizure action plan in place that includes rescue medication instructions and caregiver training 1

From the FDA Drug Label

For the treatment of status epilepticus, the usual recommended dose of lorazepam injection is 4 mg given slowly (2 mg/min) for patients 18 years and older. If seizures cease, no additional lorazepam injection is required. If seizures continue or recur after a 10- to 15-minute observation period, an additional 4 mg intravenous dose may be slowly administered In adults, a loading dose of 10 to 15 mg/kg should be administered slowly intravenously, at a rate not exceeding 50 mg per minute Other measures, including concomitant administration of an intravenous benzodiazepine such as diazepam, or an intravenous short-acting barbiturate, will usually be necessary for rapid control of seizures because of the required slow rate of administration of phenytoin

Breakthrough Seizure Management:

• Lorazepam (IV): 4 mg given slowly (2 mg/min) for patients 18 years and older. If seizures continue or recur, an additional 4 mg intravenous dose may be slowly administered.
• Phenytoin (IV): loading dose of 10 to 15 mg/kg administered slowly intravenously, at a rate not exceeding 50 mg per minute.
• Concomitant administration of an intravenous benzodiazepine or an intravenous short-acting barbiturate may be necessary for rapid control of seizures. 2 3

From the Research

Breakthrough Seizure Management

• Breakthrough seizures in patients with known epilepsy require immediate attention and management in the emergency department 4
• The emergency physician must gather information to identify the underlying cause of the seizure and decide whether the pharmaceutical management needs to be changed 4
• Clinical management decisions, especially when considering adjustment in an antiepileptic drug (AED) regimen, are often best made in coordination with a consulting neurologist 4
• Increasing emergency physicians' comfort level regarding the use of newer-generation AEDs can improve the dialogue between the emergency physician and neurologist and the dialogue with the patient 4

Treatment Options

• Levetiracetam, fosphenytoin, and valproate are commonly used treatments for breakthrough seizures and status epilepticus 5, 6
• The efficacy of these treatments can vary depending on the underlying cause of the seizure and the patient's age and medical history 5, 6
• Lamotrigine, levetiracetam, and topiramate are as effective as valproate for treating generalized tonic-clonic, tonic, and clonic seizures 7
• Valproate and ethosuximide are the best options for the treatment of absence seizures, promoting better control of seizures 7

Emergency Management

• Seizure- and epilepsy-related complications are a common cause of emergency medical evaluation, accounting for 5% of 911 calls and 1% of emergency department visits 8
• Emergency physicians and neurologists must be able to recognize and treat seizure- and epilepsy-related emergencies, including new onset seizures, breakthrough seizures, status epilepticus, and acute adverse effects of antiepileptic drugs 8
• The emergency management of epilepsy and seizures requires a comprehensive approach, including prompt recognition, treatment, and follow-up care 8