Nil by Mouth: Strategies to Prevent Seizures in Hospitalized Epilepsy Patients

There are currently no guidelines for managing antiepileptic drug administration in patients unable to swallow pills
There are currently no guidelines for managing antiepileptic drug administration in patients unable to swallow pills

For patients with seizure disorders, continuing home treatment regimens may become challenging when they are hospitalized for surgery or other medical conditions. These patients, who may be "nil by mouth" or cannot swallow pills, may need alternative antiepileptic drugs (AEDs) to prevent breakthrough seizures during this time. 

Currently, there are no evidence-based guidelines or data comparing various strategies for managing AEDs in this setting. Researchersfrom the Brigham and Women's Hospital, Boston, MA, proposed strategies for maintaining seizure control in patients with epilepsy who have medical or surgical contraindications to their typical home oral AEDs in a new study published in the journal Practical Neurology

In circumstances where a patient with epilepsy cannot take oral medications, "it is best to contact the patient's primary epileptologist if possible, in order to determine which AEDs the patient has responded to and tolerated in the past, depending on the particular epilepsy syndrome," stated lead author, Dr. Anna M. Bank. 

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Some case reports and case series have documented successful rectal administration of several AEDs in patients who cannot swallow whole pills. Rectal diazepam and diluted valproate oral solution, carbamazepine oral suspension, and intravenous (IV) lorazepam have been administered rectally for maintenance AED treatment.

Patients who are nil by mouth prior to a surgical procedure or for bowel rest require conversion to an IV AED regimen. Here, researchers present three potential strategies: 

Strategy #1: Oral-to-IV conversion of the same drug

  • When an IV formulation of the patient's home AED is available, this is the most straightforward solution
  • When converting from extended-release to IV formulation, physicians typically decrease the dose accordingly
  • Currently available AEDs with IV formulations are: acetazolamide, clonazepam, lacosamide, levetiracetam, phenobarbital, phenytoin, valproate
  • IV brivaracetam and carbamazepine  were also recently approved

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