How to decrease frequency of seizures in a patient?

[shroomysoup]

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A 66 year old female is on divalproex sodium 1500mg PO every morning & 1000mg every evening (increased from 1000mg PO BID four months ago). Her seizures have decreased from twice per week to once per week. She would be very happy if her seizures were no more than once monthly. She has generalized absence seizures and is allergic to ethosuximide (which is 1st line therapy) and levetiracetam. Would you just increase the dose of divalproex sodium? Would this decrease the frequency of the seizures even further?

 

[amerikaner]

Look into phenobarbital.

 

[TV09]

I really am not sure about this but what about Lamictal?

 

[spacecowgirl]

First I would check her VPA level.

 

[pharmacogenomic]

Not enough info.

When was onset? What has been used? What were the most recent labs like (BUN, creatinine, ALT, electroloytes, glucose)? What was the most recent VPA level?

Does she lose conciousness during seizure activity?

Has phenytoin been used? If so, why stopped?

What is the neurologist plan?

 

[pharmacogenomic]

Valproic acid levels aren't well correlated with effect

true - but they give you an indication of how much drug is unbound.

The relationship between dose and total valproate concentration is nonlinear since it is so dependent on saturable protein binding.

But, the kinetics of unbound drug are linear - which is the drug that is presented to cross the blood brain barrier....thus having the effect.

If, there is a protein binding issue, hyperlipidemia, hepatic enzyme induction, renal diseases, etc......you can see changes in the free fraction - sometimes by as much as 18-20%.

Periodic levels give you an idea of what the drug is doing outside its active compartment - not to dose to a particular level.

 

[shroomysoup]

Not enough info.

When was onset? What has been used? What were the most recent labs like (BUN, creatinine, ALT, electroloytes, glucose)? What was the most recent VPA level?

Does she lose conciousness during seizure activity?

Has phenytoin been used? If so, why stopped?

What is the neurologist plan?

Husband describes the seizures as only lasting a few seconds. Before the seizures begin, he states that she starts snapping her fingers. During the seizure though, she does not respond to him and just stares forward. She is not confused after the event.

Chem 7 is normal. AST/ALT are normal.

Serum Valproic Acid is 98 mcg/mL (in normal range I think)

The only drug used for her epilepsy is divalproex sodium.

The patient does have anemia, and it is due to uncontrolled rheumatoid arthritis.

Past medical history shows epilepsy, rheumatoid arthritis, panic disorder, hysterectomy

 

[pharmacogenomic]

What was the age of onset?

EEG findings? MRI?

What is the neurologist's plan?

Valproic acid is a relatively new drug (altho not to most of you) - compared with what a 66 yo might have been prescribed had she developed these seizures as a younger woman.

Phenobarb & phenytoin were the first line drugs 40 years ago.

Mono therapy is always better, but depending on what the neurologist feels - additional drugs may be required.

 

[shroomysoup]

What was the age of onset?

EEG findings? MRI?

What is the neurologist's plan?

Valproic acid is a relatively new drug (altho not to most of you) - compared with what a 66 yo might have been prescribed had she developed these seizures as a younger woman.

Phenobarb & phenytoin were the first line drugs 40 years ago.

Mono therapy is always better, but depending on what the neurologist feels - additional drugs may be required.

She has had epilepsy for 8 years. There aren't any EEG or MRI findings. There is no plan from a neurologist... we have to recommend therapy by ourselves.

 

[pharmacogenomic]

She has had epilepsy for 8 years. There aren't any EEG or MRI findings. There is no plan from a neurologist... we have to recommend therapy by ourselves.

What!!!?????😱

A diagnosis without a physician making it?

Hmmmm - I'm good at what I do, but I've not gone to medical school nor have I done a residency in neurology.

I could not do the complex differential diagnosis which this case entails, particularly late onset seizures, which I'm not sure is classified as epilepsy - again....not a neurologist.

I hope it is theoretical only & not actual. But, in real life, if I were to find myself needing to make a recommendation on changing therapy, I'd have to have a physician diagnosis first with that diagnosis & plan directing therapy as well as all diagnostic results which not only gives the information the physician needs to make the diagnosis, but also information you might use to make your recommendations.

If this is an educational event, it is just my opinion that you've been not been given sufficient information to make a responsible recommendation.

 

[legaldlr]

I agree with the other posts, but what type of 'allergies' does she have to etho and lamictal? Are they true allergies, or just N/V and other side effects that patients often call allergies? If this is the case, one of them may be re-considered. Mind you, after thorough neuro eval.