What is the plan for a patient experiencing a second episode of tonic-clonic seizures (convulsions)?

From the Guidelines

For a patient experiencing tonic-clonic convulsions for the second time, the recommended plan includes starting an antiepileptic medication such as levetiracetam (Keppra) at 500 mg twice daily, gradually increasing to 1000-1500 mg twice daily as tolerated, or carbamazepine (Tegretol) starting at 200 mg twice daily and titrating up to 400-600 mg twice daily, as supported by the most recent study 1. The patient should undergo an urgent neurological evaluation including an EEG to assess brain electrical activity and MRI brain imaging to rule out structural causes.

Key Considerations

• Blood tests should be performed to check electrolytes, glucose, calcium, and drug levels if applicable.
• The patient should avoid driving until cleared by their physician (typically seizure-free for 3-12 months depending on local regulations) and should avoid alcohol, sleep deprivation, and other seizure triggers.
• A seizure action plan should be created for family members, including instructions to place the person on their side during a seizure, not restrain them, remove dangerous objects, time the seizure, and call emergency services if the seizure lasts longer than 5 minutes or if multiple seizures occur without recovery. This comprehensive approach is necessary because a second seizure significantly increases the risk of future seizures, and proper medication can reduce this risk by 70-80% in most patients, as indicated by the study 1.

Medication Selection

The choice of antiepileptic medication should be based on the patient's specific needs and medical history, with levetiracetam being a commonly recommended option due to its efficacy and relatively favorable side effect profile, as demonstrated in the study 1.

Monitoring and Follow-up

Regular follow-up appointments with a neurologist are crucial to monitor the patient's response to medication, adjust the treatment plan as needed, and address any concerns or side effects, as emphasized in the clinical policy 1.

From the FDA Drug Label

Levetiracetam is indicated as adjunctive therapy in the treatment of primary generalized tonicoclonic seizures in adults and children 6 years of age and older with idiopathic generalized epilepsy. Treatment should be initiated with a dose of 1000 mg/day, given as twice-daily dosing (500 mg BID). Dosage should be increased by 1000 mg/day every 2 weeks to the recommended daily dose of 3000 mg.

The plan for a patient experiencing a second episode of tonic-clonic seizures (convulsions) is to:

• Continue or adjust the current dose of levetiracetam, with a maximum recommended daily dose of 3000 mg.
• Monitor the patient's response to treatment and adjust the dose as needed to control seizures.
• Consider consulting the prescribing information or a healthcare professional for further guidance on managing the patient's condition 2.

From the Research

Treatment Plan for Second Episode of Tonic-Clonic Seizures

The treatment plan for a patient experiencing a second episode of tonic-clonic seizures involves the use of antiepileptic drugs (AEDs) to control and prevent future seizures.

• The choice of AED depends on several factors, including efficacy, adverse effects, interactions, adherence, and mechanism of action 3.
• For patients with primary generalized tonic-clonic seizures (PGTCS), valproic acid, lamotrigine, levetiracetam, and topiramate are considered first-line treatments 4, 5.
• For patients with secondary generalized tonic-clonic seizures (SGTCS), lacosamide, perampanel, and topiramate have shown greater efficacy than placebo in preventing SGTCS 6, 5.
• The distinction between primary and secondary GTCs depends mainly on history and EEG, and yield can be improved with sleep deprivation or overnight recording 7.
• It is essential to consider the patient's individual characteristics, such as age, gender, and comorbidities, when selecting an AED 4.

Antiepileptic Drugs for Tonic-Clonic Seizures

The following AEDs are commonly used to treat tonic-clonic seizures:

• Valproic acid: considered a first-line treatment for PGTCS, but should be avoided in women of childbearing age due to its safety profile 4, 5.
• Lamotrigine: a viable alternative as a first-line treatment for PGTCS 4.
• Levetiracetam: a viable alternative as a first-line treatment for PGTCS 4.
• Topiramate: effective as a first-line treatment for PGTCS, but may have cognitive and memory adverse side effects 4.
• Lacosamide: a promising treatment for SGTCS, with greater efficacy than placebo in preventing SGTCS 6, 5.
• Perampanel: a promising treatment for SGTCS, with greater efficacy than placebo in preventing SGTCS 6, 5.