What are the next steps for a patient with a seizure disorder who had a seizure after starting Latuda (lurasidone)?

Immediate Management of Seizure After Starting Latuda in Patient with Known Seizure Disorder

Discontinue Latuda immediately and reassess the patient's baseline antiepileptic drug regimen for subtherapeutic levels or medication adherence issues. 1

Initial Assessment and Stabilization

• Check serum glucose and sodium immediately, as these are the only laboratory abnormalities that consistently alter acute management 1
• Obtain antiepileptic drug levels if the patient is on phenytoin, valproate, carbamazepine, or phenobarbital to assess for subtherapeutic levels as the potential cause 1
• Assess whether the patient has returned to neurological baseline, as this determines the aggressiveness of workup and need for admission 1

Addressing the Latuda-Seizure Connection

Latuda (lurasidone) should be discontinued in this patient. While the evidence provided does not contain specific FDA labeling for Latuda, antipsychotic medications are known to lower the seizure threshold, and a case report demonstrates seizure occurrence when switching antipsychotics in a patient with known seizure disorder 2. The temporal relationship between starting Latuda and seizure occurrence warrants immediate discontinuation.

Neuroimaging Decision

Emergency CT head without contrast is indicated if any of the following high-risk features are present 1:

• Recent head trauma
• Persistent altered mental status beyond expected post-ictal period
• New focal neurological deficits
• Fever suggesting CNS infection
• History of cancer or immunocompromised state
• Anticoagulation use

Antiepileptic Drug Management

Resume or optimize the patient's baseline antiepileptic regimen 1:

• If subtherapeutic levels are identified, reload the patient's home antiepileptic medication
• For intravenous loading, options include fosphenytoin (18 PE/kg IV at maximum rate of 150 PE/min), valproate (up to 30 mg/kg IV at max rate of 10 mg/kg/min), or levetiracetam (1,500 mg IV load) 3
• For oral loading in stable patients who have returned to baseline, phenytoin (20 mg/kg divided in maximum doses of 400 mg every 2 hours) or levetiracetam (1,500 mg oral load) are options 3

If Active Seizure Activity Persists

Administer benzodiazepines immediately for any seizure lasting >5 minutes 1, 4:

• Midazolam 0.2 mg/kg IM (maximum 6 mg per dose) may be repeated every 10-15 minutes 3
• If seizures persist after optimal benzodiazepine dosing, administer an additional antiepileptic medication such as intravenous valproate, fosphenytoin, or levetiracetam 3, 1

Disposition Decision

Admission is warranted if any of the following are present 1:

• Persistent abnormal neurological examination
• Failure to return to baseline within several hours
• Status epilepticus requiring ongoing treatment
• Concern for underlying acute process (CNS infection, hemorrhage, stroke)

Discharge may be considered if the patient 1:

• Has returned to clinical baseline
• Has normal neurological examination
• Has no persistent altered mental status
• Has no abnormal investigation results requiring inpatient management
• Has reliable neurology follow-up arrangements established

Critical Observation Period

The patient should remain under observation for at least 6 hours, as 85% of early seizure recurrences occur within this timeframe (mean time to recurrence: 121 minutes) 1, 5, 4. The overall 24-hour recurrence rate in patients with known epilepsy is 9.4% 1.

Psychiatric Medication Considerations Going Forward

Coordinate with psychiatry before restarting any antipsychotic medication, as the patient clearly requires treatment for their psychiatric condition but needs an agent with lower seizure risk. The abrupt change in antipsychotic therapy may have contributed to destabilizing seizure control 2.

Common Pitfalls to Avoid

• Do not restart Latuda without neurology and psychiatry consultation, given the temporal relationship to seizure occurrence 2
• Do not assume the seizure was simply a breakthrough seizure without checking antiepileptic drug levels and considering medication interactions 1
• Do not discharge prematurely before the 6-hour high-risk period for recurrence has passed 1, 4