Should a patient with alcohol abuse and recurrent seizures be started on antiseizure medication?

From the Guidelines

No, a patient with alcohol abuse and recurrent seizures should not be started on antiseizure medication following an alcohol withdrawal seizure, as anticonvulsants are not recommended for the prevention of further alcohol withdrawal seizures. According to the evidence-based guidelines for mental, neurological, and substance use disorders 1, benzodiazepines are recommended as front-line medication for the management of alcohol withdrawal in alleviating withdrawal discomfort, and preventing and treating seizures and delirium. Some key points to consider in the management of this patient include:

• Benzodiazepines, such as lorazepam or diazepam, can be used for acute seizure management
• Supported withdrawal from alcohol should be advised in patients with alcohol dependence
• Antipsychotic medications should not be used as stand-alone medications for the management of alcohol withdrawal
• Patients at risk of severe withdrawal, or who have concurrent serious physical or psychiatric disorders, or who lack adequate support, should preferably be managed in an inpatient setting
• As part of withdrawal management, all patients should be given oral thiamine, and those at high risk or with suspected Wernicke’s encephalopathy should be given parental thiamine. However, the most effective intervention is alcohol cessation, as continued drinking will reduce medication effectiveness and increase seizure risk. Patients should also be evaluated for other potential causes of seizures, including metabolic abnormalities, head trauma, or other neurological conditions that may coexist with alcohol use disorder.

From the Research

Patient Assessment

• The patient has a history of alcohol abuse and recurrent seizures, indicating a potential risk for alcohol withdrawal syndrome 2, 3.
• The patient's current presentation with seizure suggests a possible alcohol withdrawal seizure, which can be life-threatening if not managed properly 4, 5.

Treatment Options

• Benzodiazepines, such as lorazepam or diazepam, are considered the first-line treatment for alcohol withdrawal syndrome, including seizures 4, 2, 3, 5.
• The use of benzodiazepines has been shown to reduce the risk of recurrent seizures related to alcohol withdrawal 3.
• Other treatment options, such as anticonvulsants, barbiturates, and adrenergic drugs, have been tried but have limited evidence and are not considered first-line treatment 6.

Management Considerations

• The patient's history of alcohol abuse and recurrent seizures suggests a high risk for severe alcohol withdrawal syndrome, including seizures and delirium tremens 2.
• Close monitoring and supportive care, including vitamin supplementation, are essential in managing the patient's condition 2, 6.
• A symptom-triggered regimen, rather than a fixed tapering dose regimen, may be more effective in managing the patient's symptoms 6.

Antiseizure Medication (ASM)

• The use of ASM, such as benzodiazepines, is recommended for patients with a history of alcohol withdrawal seizures 3.
• The patient's current presentation with seizure suggests that ASM may be necessary to prevent further seizures 4, 3.
• However, the decision to start ASM should be based on a thorough assessment of the patient's condition and medical history, and should be made in consultation with a healthcare professional 2, 6.