From the Guidelines
Phenytoin is the seizure medication of choice in hepatic encephalopathy.
Seizure Management
- The use of phenytoin is recommended to control seizures in patients with hepatic encephalopathy, as stated in the 2005 AASLD position paper 1.
- Benzodiazepines should be used with caution due to their delayed clearance by the failing liver and potential to affect mental status evaluation.
- Seizures can contribute to increased intracranial pressure (ICP) and cerebral hypoxia, making prompt control crucial.
Clinical Context
- Hepatic encephalopathy (HE) is a complex condition with a wide range of neurological and psychiatric manifestations, as described in the 2014 practice guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver 1.
- While seizures are rare in HE, their occurrence can have significant clinical implications, emphasizing the need for appropriate management.
Treatment Approach
- The primary goal is to control seizures while minimizing the use of sedatives, which can interfere with mental status assessment.
- Phenytoin, with its relatively favorable pharmacokinetic profile in liver disease, is a reasonable choice for seizure management in this context.
From the Research
Seizures in Hepatic Encephalopathy
- The incidence of seizures in hepatic encephalopathy varies between 2% and 33% 2
- Non-convulsive status epilepticus may be particularly common in these patients 2
- Seizures can be an uncommon and potentially dangerous complication of hepatic encephalopathy 3
Management of Seizures
- Aims of seizure management include treatment of basic disease, correction of precipitant factors, imaging of head, and choice of a pharmacologically safe agent 2
- Drugs with sedative effects are best avoided because of a risk of precipitating coma 2
- Phenytoin and gabapentin are relatively preferred drugs; however, monitoring of drug levels is desirable 2
- Levetiracetam seems to be an attractive therapeutic option in epileptic patients with chronic liver diseases 4
- Newer antiepileptic drugs without, or with minimal, hepatic metabolism, such as levetiracetam, lacosamide, topiramate, gabapentin, and pregabalin should be used as first-line therapy 5
Choice of Antiepileptic Drugs
- Medications undergoing extensive hepatic metabolism, such as valproic acid, phenytoin, and felbamate should be used as drugs of last resort 5
- Levetiracetam and lacosamide, available in intravenous preparations, are good second-line therapies after benzodiazepines fail to control seizures 5
- Bromides, levetiracetam, gabapentin, and vigabatrin constitute safe choices in special circumstances, such as patients affected by acute intermittent porphyria 5