Anticonvulsant Agents: Acute Drug Therapy Outside Status Epilepticus

Abstract

Acute symptomatic seizures are defined as occurring in the first week after a brain lesion or an injury while provoked seizures are caused by temporary metabolic disturbances or derangements due to illicit drugs, toxins, or medication side effects or overdose. Studies on the best treatment or treatment at all for acute symptomatic seizures are scarce and lacking high class of evidence. Most recommendations therefore are based on retrospective data and supported by expert opinion. Antiseizure drugs (ASDs) for the treatment of acute symptomatic seizures should have some specific properties: As acute symptomatic seizures and provoked seizures need urgent treatment, the ideal ASD should be easily and fast to administer, ideally intravenously, and be approved for monotherapy. It should also have an almost immediate effect and not need titration up to an effective dose. Most used ASDs for the treatment of acute symptomatic seizures include levetiracetam and lacosamide, and for short-term treatment only, benzodiazepines, while ASDs requiring slow titration like lamotrigine, carbamazepine, oxcarbazepine, eslicarbazepine, topiramate, zonisamide, and perampanel are not suitable. Perampanel, pregabalin, gabapentin are not approved as monotherapy, as well as brivaracetam which might otherwise be a good candidate for the treatment of acute symptomatic seizures because of its rapid onset of action and no need of titration. Despite their availability as IV solutions, valproic acid and, especially, phenytoin are not recommended for the use in acute symptomatic seizures because of their severe acute adverse effects on multiple organ systems and their large potential of serious drug–drug interactions.