Treatment for Seizures
The recommended first-line treatment for seizures is benzodiazepines (such as lorazepam 4 mg IV) for active seizures, followed by antiepileptic medications like levetiracetam, valproate, or phenytoin as second-line agents based on seizure type and patient characteristics. 1, 2
Initial Management of Active Seizures
First-Line Treatment
- Benzodiazepines: Lorazepam 0.1 mg/kg IV (maximum 4 mg) is the preferred first-line agent for status epilepticus, with option to repeat once after 5 minutes if seizures persist 2
- Success rate of approximately 65% for terminating seizure activity 2
- Primary adverse effect is respiratory depression
Second-Line Treatment (if seizures persist after benzodiazepines)
Levetiracetam: 30-50 mg/kg IV (maximum 2500 mg)
Valproate: 20-30 mg/kg IV at rate of 40 mg/min
Phenytoin/Fosphenytoin: 18-20 mg/kg IV
- Success rate of approximately 56% 1
- Adverse effects: hypotension, cardiac dysrhythmias, purple glove syndrome
- Slower administration required (maximum 50 mg/min for phenytoin)
Refractory Status Epilepticus Management
For seizures that fail to respond to benzodiazepines and second-line agents:
Level A recommendation: Administer an additional antiepileptic medication 1
Level B recommendation: Consider IV phenytoin, fosphenytoin, or valproate 1
Level C recommendation: Consider IV levetiracetam, propofol, or barbiturates 1
Phenobarbital: 10-20 mg/kg IV; may repeat 5-10 mg/kg after 10 minutes
- Success rate of approximately 58% 1
- Adverse effects: respiratory depression, hypotension
Propofol: 2 mg/kg bolus; may repeat in 3-5 minutes; maintenance infusion of 5 mg/kg/h
- Requires respiratory support
- May cause hypotension 1
Long-Term Seizure Management
Focal Onset Seizures
- Levetiracetam: Start with 500 mg BID, titrate by 1000 mg/day every 2 weeks to target dose of 3000 mg/day 3
- Lamotrigine: Evidence shows better treatment retention compared to carbamazepine 4
Generalized Seizures
- Valproate: First-line for generalized tonic-clonic seizures 4
- Levetiracetam or Lamotrigine: Alternative first-line options, particularly when valproate is contraindicated 2, 4
Special Populations
Women of childbearing potential:
- Avoid valproate due to teratogenicity
- Prefer levetiracetam or lamotrigine 2
Elderly patients:
- Start with lower doses and titrate slowly
- Prefer medications with minimal drug interactions like levetiracetam 2
Patients with cardiac conditions:
- Avoid carbamazepine
- Consider levetiracetam as a safer alternative 2
Patients with renal impairment:
- Adjust dosing based on creatinine clearance
- For levetiracetam with creatinine clearance <30 mL/min, reduce dose to 250-500 mg every 12 hours 3
Important Considerations and Pitfalls
Avoid prophylactic antiseizure medications if no clear seizure activity is confirmed 2
Monitor for drug interactions: Enzyme-inducing AEDs (carbamazepine, phenytoin) may interact with other medications 5
Regular monitoring should include:
- Seizure frequency and characteristics
- Medication adherence
- Side effects
- Drug levels when appropriate 2
Common adverse effects across antiepileptic drugs include drowsiness/fatigue, headache, gastrointestinal disturbances, dizziness, and skin rash 2
Consider tapering medication after 2 years of seizure freedom if EEG is normal 2
The choice of antiepileptic medication should be guided by seizure type, patient characteristics, and potential adverse effects. While many medications have similar efficacy, their side effect profiles and pharmacokinetics differ significantly, making the selection process critical for optimal seizure control and patient quality of life.