Seizures (generalised or partial) occur in 10 to 15% of palliative care patients most often due to primary or secondary brain tumours, cerebrovascular disease, epilepsy or biochemical abnormalities (e.g.such as low sodium, hypercalcaemia, uraemia).
An advance care plan is particularly important for people at risk of seizures, and may help to avoid unnecessary hospital admission.
- Exclude other causes of loss of consciousness or abnormal limb or facial movement (e.g.for example vasovagal episode (faint), postural hypotension, arrhythmia, hypoglycaemia, extrapyramidal side effects from dopamine antagonists, alcohol).
- Find out if the patient has had previous seizures or is at risk – history of epilepsy, previous secondary seizure, known cerebral disease.
- Is there a problem with usual anti-epileptic drug therapy? – unable to take oral medication, drug interactions (for example corticosteroids reduce the effect of carbamazepine, phenytoin) – check British National Formulary (BNF).
Refer to Figure 1 below.
- Most patients with a structural cause for seizures benefit from treatment after their first seizure.
- Follow Scottish Intercollegiate Guidelines Network (SIGN) or National Institute for Health and Clinical Excellence (NICE) guideline recommendations (see links in References section of this guideline). Check BNF for drug interactions. Choice of anti-epileptic medicine is guided by seizure type, potential for drug interactions, comorbidities and simplicity of the regimen.
- Partial or secondary generalised seizures: sodium valproate, carbamazepine, or lamotrigine. Levetiracetam can be considered in line with Scottish Medicines Consortium (SMC) guidance when traditional first-line treatments are ineffective or unsuitable.
- Primary generalised seizures (unlikely in palliative setting): sodium valproate or lamotrigine.
- Dying patient unable to take oral medication: anti-epileptics have a long half-life so additional anticonvulsant treatment may not be needed. Alternatives are:
- midazolam 10mg buccal* or 5mg subcutaneously (SC) or diazepam rectal solution 10mg rectally, if required
- midazolam 20 to 30mg continuous subcutaneous infusion over 24 hours can be used as maintenance therapy
The following drugs are not licensed for status epilepticus in adults
- Midazolam *
- Phenobarbital (at dose stated)
- Diazepam rectal solution via stoma
- Lorazepam is preferred to diazepam as it gives longer control of seizures and has reduced cardiorespiratory depression but may not be available in all settings.
- Midazolam injection can be given buccally, or newer buccal preparations are available (see ‘Further information’ section of this guideline) and may maintain more dignity than rectal diazepam.
- Although first seizures are not usually treated, for those with intracranial tumours AEDs (anti-epileptic drugs) are normally commenced following first seizure. There is no evidence of benefit of prophylactic AEDs (before any seizure occurs).
- Consider commencement of, or review of, dose of corticosteroid in those with intracranial tumour and seizure.
- Levetiracetam and lamotrigine do not significantly induce enzymes and will have minimal interactions with other medications such as chemotherapy.
- Monitor effect of medication which can lower seizure threshold, such as haloperidol or levomepromazine; review need and dose if there is definite exacerbation of seizure activity as a result.
Patient and carer advice points
- Seizures are frightening to patients and their families. Educate and address any concerns, such as desired management of further seizures, management of risk of seizure recurrence if stopping AEDs, for example due to swallowing difficulties.
- If relevant, it is important to remind patients that AED treatment would be life-long and that there are implications for driving following seizures.
- More information can be obtained from NHS Inform and also from Macmillan Cancer Support.
*Buccolam® (midazolam 5mg/ml) is unlicensed for use in adults. Epistatus® (midazolam 10mg/ml) is currently unlicensed. Check local policy.