Central Nervous System Regulation, Mood, and Cognition
8.10 Anticonvulsants
Medications used for seizures are called anticonvulsants or antiseizure drugs. Antiseizure drugs stabilize cell membranes and suppress the abnormal electric impulses in the cerebral cortex. These drugs prevent seizures but do not provide a cure. Antiseizure drugs are classified as CNS depressants. There are many types of medications used to treat seizures such as phenytoin, phenobarbital, benzodiazepines, carbamazepine, valproate, and levetiracetam.[1]
There are three main pharmacological effects of antiseizure medications. First, they increase the threshold of activity in the motor cortex, thus making it more difficult for a nerve to become excited. Second, they limit the spread of a seizure discharge from its origin by suppressing the transmission of impulses from one nerve to the next. Third, they decrease the speed of the nerve impulse conduction within a given neuron.
Some drugs work by enhancing the effects of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA), which plays a role in regulating neuron excitability in the brain.[2] Gabapentin, although structurally similar to GABA and classified as an anticonvulsant, is commonly used to control chronic neuropathic pain. Neuropathic pain is defined by the International Association for the Study of Pain as “pain caused by a lesion or disease of the somatosensory nervous system.”[3] An example of neuropathic pain is tingling or burning in the lower extremities that often occurs in clients with diabetes.
Phenytoin
Phenytoin, which was discovered in 1938, was the first anti-seizure medication and is still being used to control seizures.[4]
Mechanism of Action
Phenytoin improves evidence of seizures by interfering with sodium channels in the brain, resulting in a reduction of sustained high-frequency neuronal discharges.
Indications for Use
Phenytoin is indicated for the treatment of tonic-clonic (grand mal) and psychomotor (temporal lobe) seizures and for the prevention and treatment of seizures occurring during or following neurosurgery.
Nursing Considerations Across the Lifespan
Phenytoin should not be administered to pregnant women because it will cause harm to the fetus. When given intravenously, there is a Black Box Warning that the rate of administration should not exceed 50 mg per minute in adults and 1 to 3 mg/kg/min (or 50 mg per minute, whichever is slower) in pediatric clients because of the risk of severe hypotension and cardiac arrhythmias. Careful cardiac monitoring is needed during and after administering intravenous phenytoin.
Phenytoin has a narrow therapeutic drug level, usually between 40 – 80 uM/L, so serum drug monitoring is required.[5]Serum levels of phenytoin sustained above the therapeutic range may produce confusional states referred to as delirium, psychosis, or encephalopathy. Accordingly, at the first sign of acute toxicity, serum levels should be immediately checked.
Abrupt discontinuation can cause status epilepticus, so in the event of an allergic or hypersensitivity reaction, rapid substitution of alternative therapy may be necessary.
Use with caution in clients with renal or hepatic impairment. Elderly clients may require dosage adjustment.
There are many potential drug interactions with phenytoin. Read drug label information before administering. Phenytoin is extensively bound to plasma proteins and is prone to competitive displacement. Phenytoin is metabolized by hepatic cytochrome P450 enzymes, so it is susceptible to inhibitory drug interactions, which may produce significant increases in circulating phenytoin concentrations and enhance the risk of drug toxicity.
Adverse/Side Effects
Serious and sometimes fatal dermatologic reactions, including toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS), have been reported with phenytoin treatment. The onset of symptoms is usually within 28 days but can occur later. Phenytoin should be discontinued at the first sign of a rash.
Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) has been reported in clients taking antiepileptic drugs, including phenytoin. Some of these events have been fatal or life-threatening. DRESS typically presents with fever, rash, lymphadenopathy, and/or facial swelling, in association with other organ system involvement. These findings should be immediately reported to the provider. Acute hepatotoxicity has been reported with phenytoin. These events may be part of the spectrum of DRESS or may occur in isolation.
Hematopoietic complications, some fatal, have occasionally been reported in association with the administration of phenytoin. These have included thrombocytopenia, leukopenia, granulocytopenia, agranulocytosis, and pancytopenia with or without bone marrow suppression.
The most common adverse reactions encountered with phenytoin therapy are nervous system reactions and are usually dose-related. Reactions include nystagmus, ataxia, slurred speech, decreased coordination, somnolence, and mental confusion.[6]
Client Teaching & Education
Clients should be advised to take medications as directed and that doses should be evenly spaced throughout the day. It may take several weeks to obtain the desired medication effect. Abrupt withdrawal of medication may cause status epilepticus. Clients should avoid alcohol and other CNS depressants while taking anticonvulsant drug therapy. Additionally, diabetic clients should monitor their blood glucose levels carefully.
Phenytoin Medication Card
Now let’s take a closer look at the medication card for phenytoin.[7] Medication cards like this are intended to assist students to learn key points about each medication. Because information about medication is constantly changing, nurses should always consult evidence-based resources to review current recommendations before administering specific medication. Basic information related to each class of medication is outlined below. Prototype or generic medication examples are also hyperlinked to a free resource at Daily Med. On the home page, enter the drug name in the search bar to read more about the medication.
Medication Card 8.10.1: Phenytoin
Generic Name: phenytoin
Prototype/Brand Name: Dilantin
Mechanism: interfering with sodium channels in the brain, resulting in a reduction of sustained high-frequency neuronal discharges.
Therapeutic Effects
- Reduced seizure activities
Administration
- Must be administered slowly
- IV: cardiac monitoring and in-line filter
- caution in clients with renal or hepatic impairment.
- Elderly clients may require dosage adjustment.
Indications
- Decrease or prevent seizure activity
Contraindications
- Pregnancy
- Heart block
- Several drug interactions
Side Effects
- Common adverse reactions: Reactions include nystagmus, ataxia, slurred speech, decreased coordination, somnolence, and mental confusion
- SAFETY: Serious/fatal effects: dermatologic reactions, TEN, SJS, DRESS, Hematopoietic complications, Acute hepatotoxicity
Nursing Considerations
- Requires serum drug monitoring
- Taper dose; do not stop abruptly
- Monitor blood glucose closely
- Avoid alcohol and CNS depressants
- Must administer slowly.
- Discontinue at first sign of a rash
Levetiracetam
Levetiracetam is indicated as adjunctive therapy in the treatment of partial-onset seizures in clients 12 years of age and older with epilepsy. It is generally well-tolerated.
Mechanism of Action
The exact mechanism of action is unknown. This medication may interfere with sodium, calcium, potassium, or GABA transmission.[8]
Indications for Use
Levetiracetam is used for partial-onset seizures in clients with epilepsy.
Nursing Considerations Across the Lifespan
Plasma levels can gradually decrease during pregnancy and should be monitored closely. Safety and effectiveness in pediatric clients 12 years of age and older have been established.
Levetiracetam immediate release and solution can be used in clients as young as 1 month.
Levetiracetam should not be stopped abruptly or withdrawal seizures may occur. Use with caution in clients with renal impairment.
Adverse/Side Effects
Behavioral abnormalities including psychotic symptoms, suicidal ideation, irritability, and aggressive behavior have been observed; monitor clients for psychiatric signs and symptoms.
The most common adverse reactions are somnolence and irritability. Advise clients not to drive or operate machinery until they have gained sufficient experience on levetiracetam.
This drug can cause anaphylaxis or angioedema after the first dose or at any time during treatment. Serious dermatological reactions, including Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), have been reported, as well as coordination difficulties and hematologic abnormalities.
Client Teaching & Education
Medications should be taken as directed and may cause increased dizziness and somnolence. Clients, family, and caregivers should also monitor carefully for suicidality during medication therapy.
Levetiracetam Medication Card
Now let’s take a closer look at the medication card for levetiracetam.[9] Because information about medication is constantly changing, nurses should always consult evidence-based resources to review current recommendations before administering specific medication.
Medication Card 8.10.2: Levetiracetam
Generic Name: levetiracetam
Prototype/Brand Name: Keppra
Mechanism: Exact mechanism unknown. May interfere with sodium, calcium, potassium, or GABA transmission.
Therapeutic Effects
- Reduction of seizure activity
Administration
- Monitor plasma levels for pregnant women
- Use cautiously if renal impairment
- Safe for children 12 and older
Indications
- Adjunctive therapy in the treatment of partial onset seizures
Contraindications
- Clients who are suicidal
- Clients with altered hematology
Side Effects
- Behavioral/mood changes
- Somnolence, fatigue, and irritability
- Coordination difficulties
- SAFETY: Serious/fatal effects Anaphylaxis or angioedema, dermatologic reactions, TEN, SJS, Hematopoietic complications
Nursing Considerations
- Taper dose: do not stop abruptly or seizures may occur
- monitor carefully for suicidality during medication therapy.
- Monitor for safety mobility and falls risk
Gabapentin
Gabapentin is indicated as an adjunct treatment for partial seizures, but is most commonly used to treat neuropathic pain.[10]
Mechanism of Action
The exact mechanism of action is unknown. It is structurally similar to GABA, but does not act on GABA receptors or influence GABA.
Indications for Use
Gabapentin is used for partial seizures and neuropathic pain.
Nursing Considerations Across the Lifespan
This drug can cause harm to the fetus of pregnant women.
Gabapentin use in pediatric clients with epilepsy 3 to 12 years of age is associated with the occurrence of central nervous system-related adverse events. The most significant of these can be classified into the following categories: 1) emotional lability (primarily behavioral problems); 2) hostility, including aggressive behaviors; 3) thought disorder, including concentration problems and change in school performance; and 4) hyperkinesia (primarily restlessness and hyperactivity).
In elderly clients, peripheral edema and ataxia tends to increase in incidence with age. Fall precautions should be considered.
Antiepileptic drugs should not be abruptly discontinued because of the possibility of increasing seizure frequency.
Adverse/Side Effects
Antiepileptic drugs, including gabapentin, increase the risk of suicidal thoughts or behavior in clients taking these drugs for any indication. Clients should be monitored for the emergence or worsening of depression, suicidal thoughts or behavior, and/or any unusual changes in mood or behavior.
Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS), also known as multiorgan hypersensitivity, has been reported in clients taking antiepileptic drugs, including gabapentin. Some of these events have been fatal or life-threatening. DRESS typically, although not exclusively, presents with fever, rash, and/or lymphadenopathy, in association with other organ system involvement. If these symptoms occur, they should be immediately reported to the provider.
Gabapentin may cause dizziness, somnolence, and other symptoms and signs of CNS depression. Clients should be advised neither to drive a car nor to operate other complex machinery until they have gained sufficient experience on gabapentin to gauge whether or not it affects their mental and/or motor performance adversely.[11]
Client Teaching & Education
Clients receiving gabapentin therapy should take medication as directed and be careful not to exceed dosage recommendations. Clients should not take gabapentin within 2 hours of antacid medications. Additionally, gabapentin may cause increased drowsiness and dizziness. Clients, family, and caregivers should also monitor for suicidality.
Gabapentin Medication Card
Now let’s take a closer look at the medication card for gabapentin.[12] Because information about medication is constantly changing, nurses should always consult evidence-based resources to review current recommendations before administering specific medication.
Medication Card 8.10.3: Gabapentin
Generic Name: gabapentin
Prototype/Brand Name: Neurontin
Mechanism: The exact mechanism of action is unknown. It is structurally like GABA but does not act on GABA receptors or influence GABA.
Therapeutic Effects
- Reduction in seizures
- Reduction in neuropathic pain
Administration
- Administer first dose at bedtime to decrease dizziness and drowsiness
- Caution in use with children and elderly
Indications
- Adjunct treatment for partial seizures,
- Most often used to treat neuropathic pain.
Contraindications
- Pregnancy
Side Effects
- Increased suicidal ideation
- Immediately report fever, rash, and/or lymphadenopathy
- CNS depression: dizziness, somnolence, and ataxia
- DRESS
- SAFETY: Consider falls precautions for elderly. Monitor closely for suicidal ideation and DRESS syndrome.
Nursing Considerations
- Do not take within 2 hours of antacid medications.
- Taper dose; do not stop abruptly
- Monitor for worsening depression, suicidal thoughts, or behavior, and/or any unusual changes in mood or behavior
A 70-year-client in a long-term care center has diabetes and has been prescribed gabapentin for neuropathic pain.
1. The client states, “I have never had a seizure. Why has the doctor prescribed an antiseizure medication for me?” What is the nurse’s best response?
2. The nurse plans to implement additional fall precautions for this client. Why are additional fall precautions needed?
3. What potential adverse effects should the nurse plan to monitor? What adverse effects would require immediate notification of the provider?
Note: Answers to the Critical Thinking activities can be found in the “Answer Key” sections at the end of the book.
- McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, & Yeager, J. (2018). Pharmacology: A patient-centered nursing process approach. pp. 227-305. Elsevier. ↵
- Lilley, L., Collins, S., & Snyder, J. (2020). Pharmacology and the Nursing Process. pp. 246-272. Elsevier. ↵
- Murnion B. P. (2018, June 1). Neuropathic pain: current definition and review of drug treatment. Australian prescriber, 41(3), 60–63. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6003018/ ↵
- McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, & Yeager, J. (2018). Pharmacology: A patient-centered nursing process approach. pp. 227-305. Elsevier. ↵
- London Health Science Center. (2021). Phenytoin. https://www.lhsc.on.ca/critical-care-trauma-centre/phenytoin-dilantin ↵
- This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. ↵
- This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. ↵
- This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. ↵
- This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. ↵
- Lilley, L., Collins, S., & Snyder, J. (2020). Pharmacology and the Nursing Process. pp. 246-272. Elsevier. ↵
- This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. ↵
- This work is a derivative of Daily Med by U.S. National Library of Medicine in the public domain. ↵
Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS): A condition reported in patients taking antiepileptic drugs. Some of these events have been fatal or life-threatening. DRESS typically presents with fever, rash, lymphadenopathy, and/or facial swelling.