Should a hospice patient with a brain mass and intracranial hemorrhage (ICH) be on anti-seizure medications?

Anti-Seizure Medications in Hospice Patients with Brain Mass and Intracranial Hemorrhage

Anti-seizure medications should not be used prophylactically in hospice patients with brain mass and intracranial hemorrhage who have never had a seizure, as they provide no benefit and may worsen quality of life. 1

Evidence-Based Approach to Seizure Management in Hospice

When NOT to Use Anti-Seizure Medications:

• Prophylactic use in patients without history of seizures is not recommended 1
• Current guidelines from the Society for Neuro-Oncology (SNO) and American Heart Association/American Stroke Association (AHA/ASA) advise against routine prophylactic anti-seizure medications in patients with brain metastases or ICH 1
• Prophylactic anti-seizure medications have shown no significant benefit in reducing seizure development in randomized studies 1
• Most studies suggest prophylactic anti-seizure drugs (especially phenytoin) are associated with increased death and disability in ICH 1

When TO Use Anti-Seizure Medications:

1. Active seizures: Patients who have experienced clinical seizures should receive treatment 1
2. Electrographic seizures: Patients with EEG-confirmed seizures and altered mental status should be treated 1
3. High-risk features: Consider treatment only if the patient has specific high-risk features:
   • Cortical involvement of the brain mass/ICH 1
   • Melanoma brain metastases 1
   • Large burden of untreated supratentorial disease 1
   • Recent local therapy (stereotactic radiation, neurosurgical resection) 1

Medication Selection for Hospice Patients

If treatment is indicated (patient has had seizures or has high-risk features):

Preferred Agents:

• Levetiracetam:

  • First choice due to minimal side effects, favorable safety profile 1, 2
  • Dosage: 500mg twice daily, with target dose of 1000-1500mg twice daily 2
  • May need dose reduction in kidney dysfunction 2
  • Associated with better cognitive outcomes compared to phenytoin 3

• Alternatives:

  • Lacosamide: Good option with minimal drug interactions 1, 4
  • Valproic acid: Effective option but with more side effects 1, 4

Agents to AVOID:

• Phenytoin/Fosphenytoin: Associated with excess morbidity and mortality 1
• Enzyme-inducing AEDs (phenytoin, phenobarbital, carbamazepine): Can affect metabolism of other medications 1

Duration of Treatment

• If the patient has had seizures, short-term treatment (≤7 days) is reasonable 1, 2
• Extended use beyond 7 days is not effective for reducing future seizure risk in patients without prior epilepsy 1, 2
• For hospice patients, the focus should be on comfort and quality of life rather than long-term seizure prevention

Special Considerations in Hospice Care

• Quality of life impact: Anti-seizure medications can cause sedation, cognitive impairment, and drug interactions that may worsen quality of life in already vulnerable hospice patients
• Medication burden: Reducing unnecessary medications is particularly important in hospice care
• Route of administration: For patients unable to take oral medications, levetiracetam and valproic acid can be administered intravenously 4
• Monitoring: If on anti-seizure medication, monitor for side effects including somnolence, dizziness, and behavioral changes that may impact quality of life

Practical Approach for Hospice Patients

1. For patients without seizure history: Avoid prophylactic anti-seizure medications
2. For patients with seizure history: Use levetiracetam as first-line therapy
3. For patients with high seizure risk: Consider short-term prophylaxis with levetiracetam
4. For all patients: Focus on comfort measures and quality of life

Remember that in hospice care, the primary goal is comfort and quality of life. Unnecessary medications that don't improve these outcomes should be avoided.