Treatment should always be started with a single drug, but the choice of an anticonvulsant can only be made on an individual basis and will depend on the efficacy of the drug and the patient's tolerance of treatment.
Barbiturates are used as antiepileptic agents. They can, however, produce central sedation, although they may produce paradoxical excitement and hyperactivity in children. The elderly are particularly sensitive to central depressant adverse effects and may experience confusion. Phenobarbitone is used in all forms of epilepsy with the exception of absence seizures. It has been widely used in children and neonates in particular, perhaps because of convenience of administration and linear pharmacokinetics, but there is concern about its effects on cognition.
The use benzodiazepines for the long-term treatment of epilepsy is limited by problems of tolerance, sedation, and the development of dependence; withdrawal seizures are also a problem. Diazepam is not used in the prophylaxis of epileptic seizures but is of value in the treatment of febrile convulsions.
Withdrawal:
Treatment is normally continued for a minimum of two years after the lost seizure. Withdrawal should be extended over a period of several months since abrupt withdrawal can lead to complications such as status epilepticus. Abrupt discontinuation is therefore never warranted. Many adult patients relapse once treatment is withdrawn and it may be justified to continue treatment indefinitely, particularly when the patient's livelihood or lifestyle can be endangered by recurrence of a seizure.
Pregnancy and Breastfeeding;
Antiepileptic treatment may be teratogenic, the risk being increased when several drugs are given. However, generalized convulsions may be harmful or fatal to both foetus and mother and epilepsy if untreated has been associated with an increased incidence of foetal abnormalities; therefore there is no justification for abrupt withdrawal of treatment although withdrawal of therapy may be an option if the patient has been seizure free for at least 2 years; resumption of treatment antiepileptics are continued in pregnancy, mono therapy with the lowest effective dose is preferred, with adjustment made to take account of changes in plasma levels associated with pregnancy. The risk of teratogenicity with phenobarbitone appears to be lower than other antiepileptic agents, although with phenobarbitone there may be neonatal sedation and drug dependence if given close to term. In view of the risk of neonatal bleeding associated with phenobarbital, prophylactic phytomenadione (vitamin k1) is recommended for the neonatal and the mother before delivery. Anti-epileptic drugs can be continued during breastfeeding.
Diazepam
Suppository, 5mg, 10mg
Injection, 5mg/ml in 2ml ampoule
Indications:- as adjunct in static epilepticus and severe recurrent convulsive seizures.
Cautions, Drug interactions, Contraindications, & Side effects; see notes on diazepam section 4.2
Dose and Administration:
Adult - Anticonvulsants - IV, 5-10mg initially, the dosage being repeated, if necessary, at 10-15 minutes interval up to a maximum dose of 30mg.
Child |
- Anti convulsant - status epilepticus and severe recurrent convulsive seizures.
- Infants over 30 days of age and children up to 5 years of age
- IV (slow) -0.2 to 0.5 mg every 2-5 minutes up to a maximum of 5mg. If necessary, therapy should be continued.
Children 5 and older - IV (slow) - 1mg every two to five minutes up to a maximum of 5mg. If necessary, therapy may be repeated in two or four hours.
Elderly - Anticonvulsant - IM or IV, initially, 2 to 5 mg per dose, the dosage being increased gradually as needed and tolerated. |
Storage: - Store at room temperature. Protect from light and freezing.
Phenobarbitone (Phenobarbital)
Tablets,15mg, 30mg, 100mg.
Elixir,20mg/5ml
Injection (sodium),25mg/ml in 1ml ampoule; 100mg/ml in 2ml ampoule; 4%
Indications: - for the control of seizures (epilepsy).
Long - acting barbiturate is indicated as long-term anticonvulsant therapy for the treatment of generalized tonic-clonic and simple partial (cortical focal) seizures.
Cautions: - liver or renal diseases, acute or chronic pain, in weak patients, in children and the elderly, during pregnancy, labour, delivery, and breast-feeding. It has a sedative effect, and driving and operating machines should be avoided.
Also treatment should not be stopped abruptly as rebound seizures may occur.
Drug interactions: central nervous system (CNS) depressants (e.g. alcohol), paracetamol, isoniazid, and choramphenicol; and oral contraceptives containing estrogens.
Contraindications: respiratory depression.
Side effects: drowsiness or sedation, respiratory depression, and a hangover effect may occur more frequently.
Unusual excitement may occur in children, the elderly, and in patients with severe pain. It should be discontinued if severe skin reactions with fever occur.
Continued use may result in psychic or physical dependence. With excessive doses in coordination of muscular motion and continuous rolling movement of eyeball may also occur.
Dose and Administration: Orally. Several weeks (2-3) of therapy may be required to achieve maximum antiepileptic effect.
Adults :Oral, 50 - 100mg every 12 hours daily.
Children: Oral, 15 - 50 mg every 12 hours daily. Or 1 -2mg/kg of body weight every 8 hours daily.
Anticonvulsant, Adult, Oral, 60-250mg per day as a single dose - or in divided dose; IV -100-320mg, repeated if necessary up to a total dose of 600mg during a 24 hour period; Children, Oral, 1 to 6mg per kg of body weight per day as a single dose or in divided doses.
Status epilepticus - IV (slow), 10 to 20mg per kg of body weight, repeated, if necessary.
Storage: -at room temperature, in a well-closed container.
