4.6 Seizures

4.6.1 Epilepsy

Antiepileptics

• Refer to NICE NG217 - Epilepsy
• Please see guidance from MHRA on prescribing of antiepileptics (when used for seizure control) by brand/specific manufacturer’s product.  
• Lamotrigine is considered to be in Category 1 by Consultants locally and therefore patients should be maintained on a specific manufacturer’s product when prescribed for seizure control. Consultants would like to be consulted before any change is made to the patients lamotrigine brand/manufacturer prescribing.
• Secondary care - Pharmacists and medicines management technicians when reconciling medications should confirm with the patient if they normally receive branded medicines and endorse the details on the drug chart. Requests to dispense antiepileptics should be done by brand.

Recommended:

Carbamazepine (TLS Amber Specialist Recommended)

Lamotrigine (TLS Amber Specialist Recommended)

Sodium valproate (oral) (TLS Amber 3 months)

• Shared Care Protocol
• Valproate must only be considered for epilepsy where there is no suitable alternative treatment.
• Not for routine use in women of childbearing potential - use in exceptional circumstances only - see MHRA Drug Safety Update and MHRA guidance 
• See NHSE Decision support tool: is valproate the right epilepsy treatment for me?
• Very easy read (VERA) leaflets for valproate are available
• Original pack dispensing of valproate exceptions risk assessment form

Valproate safety support resources can be found here. 

Sodium valproate injection (TLS Red)

• Not for routine use in women of childbearing potential- use in exceptional circumstances only - see MHRA Drug Safety Update April 2017

Valproate safety support resources can be found here.

Alternatives:

Gabapentin (TLS Amber Specialist Recommended)

Phenytoin (TLS Amber Specialist Recommended)

Specific indications:

These agents are indicated when symptoms have not been controlled with other antiepileptics. They may only be prescribed on the recommendation of a specialist:

Acetazolamide (TLS Amber Specialist Recommended)

Brivaracetam (TLS Amber Specialist Initiated) 

• For patients with partial onset epilepsy who have tried and failed on adjunctive therapy including levetiracetam

Clobazam (TLS Amber Specialist Recommended)

• Solid dosage forms should be used where suitable.
• Where a liquid preparation is required, 10mg/5ml is the recommended formulation in BNSSG. 

Clonazepam (TLS Amber Specialist Recommended)

Eslicarbazepine (TLS Amber Specialist Initiated) 

• Specialist responsible for monitoring serum sodium during initiation phase of treatment where this is indicated e.g. for patients with pre-existing renal conditions associated with low sodium levels or in patients taking other sodium-lowering medicines - 2 weeks after initiation and then monthly for the first 3 months.

Ethosuximide (TLS Amber Specialist Recommended)

Levetiracetam (TLS Amber Specialist Recommended)

Levetiracetam (parenteral) (TLS Amber Specialist Recommended)

• For palliative patients, under the advice of a specialist palliative care consultant, who are unable to take their oral antiepileptics to treat seizures.

Oxcarbazepine (TLS Amber 3 months) (SCP click here)

Phenobarbital (TLS Amber Specialist Recommended)

Primidone (TLS Amber Specialist Recommended)

Tiagabine (TLS Amber Specialist Recommended)

Topiramate (TLS Amber Specialist Initiated)

• Topiramate should not be used:

  • in pregnancy for prophylaxis of migraine

  • in pregnancy for epilepsy unless there is no other suitable treatment

  • in women of childbearing potential unless the conditions of the Pregnancy Prevention Programme are fulfilled.

  The use of topiramate during pregnancy is associated with significant harm to the unborn child. Harms included a higher risk of congenital malformation, low birth weight and a potential increased risk of intellectual disability, autistic spectrum disorder and attention deficit hyperactivity disorder in children of mothers taking topiramate during pregnancy - see MHRA Drug Safety Update for information (June 2024).

Topiramate Safety Support Resources can be found here.

Specific indications:

Lacosamide (TLS Amber 3 months) (SCP click here)

• Initiation by Consultant in Neurology and Neuropsychiatry only for patients with intractable epilepsy
• UHB only - diabetic neuropathy (TLS Amber) (Unlicensed indication)

Perampanel (TLS Amber Specialist Initiated)

• Initiated by a specialist for the adjunctive treatment of partial-onset seizures with or without secondarily generalised seizures in patients with epilepsy aged 12 years and older who have failed on treatment with all first and second line agents

Pregabalin (TLS Amber Specialist Initiated) 

• Initiation by Consultant in Neurology and Neuropsychiatry only for patients with intractable epilepsy

• Caution – Use Pregabalin with caution in women of childbearing age. Effective contraception should be used during treatment and avoid use in pregnancy unless clearly necessary – see MHRA Drug Safety Update (April 2022)

Rufinamide (TLS Amber Specialist Initiated)

• Initiated by a specialist for the treatment of Lennox-Gastaut syndrome (licensed) or as an option in the adjunctive treatment of tonic or atonic seizures (unlicensed)

Vigabatrin (TLS Red)

• Initiated & supervised by a specialist

Zonisamide (TLS Amber Specialist Initiated) 

• Initiation by Consultant in Neurology and Neuropsychiatry only for patients with intractable epilepsy

Cannabidiol (Epidyolex^®) (TLS Red)

• NICE TA614 in combination with clobazam for treating seizures associated with Dravet Syndrome
• NICE TA615 in combination with clobazam for treating seizures associated with Lennox-Gastaut Syndrome
• NICE TA873 Cannabidiol for treating seizures caused by tuberous sclerosis complex

Cenobamate (TLS Amber Specialist Initiated)

• NICE TA753 Cenobamate for treating focal onset seizures in epilepsy

Fenfluramine (TLS Red)

• NICE TA808 Fenfluramine for treating seizures associated with Dravet syndrome

4.6.2 Status epilepticus

NICE Pathway March 2015 -Treating prolonged or repeated seizures and convulsive status epilepticus

Recommended: (TLS Green)

Lorazepam (parenteral)

Midazolam (buccal)

• For use in the community

Alternatives:

Diazepam rectal tubes (TLS Red)

Diazepam (parenteral) (TLS Red)

Clonazepam (parenteral) (TLS Red)

Levetiracetam (parenteral) (TLS Red)

Sodium valproate (parenteral) (TLS Red)

Valproate safety support resources can be found here.

Phenytoin (slow intravenous injection) (in accordance with BNF) (TLS Blue)

Phenobarbital (parenteral) (TLS Red)

Specific indications:

Paraldehyde specialist use (TLS Red)

Propofol (TLS Red)

Sodium thiopentone specialist use (TLS Red)

Midazolam (parenteral) specialist use (TLS Red)

Thiamine (parenteral) as Pabrinex^® (TLS Red)

• Alcohol abuse (see Chapter 9.6)

Pyridoxine (TLS Blue)

• Pyridoxine deficiency (see Chapter 9.6.2)

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