Antiseizure agents (also known as antiepileptic drugs or as anticonvulsants) are drugs used to manage

epilepsy, the most prevalent neurological disorder. Antiseizure agents of choice depends on the type of
epilepsy, age of the patient, patient tolerance, and specific patient characteristics.

Antiseizure Agents: Generic and Brand Names

Here is a table of commonly encountered antiseizure agents, their generic names, and brand names:

Classifications Generic Name Brand Name

Drugs for treatment of generalized seizure

Hydratoins ethotoin Peganone

fosphenytoin Cerebyx

phenytoin Dilantin

Barbiturates and barbiturate-like drugs mephobarbital Mebaral

phenobarbital Solfoton, Luminal

primidone Mysoline

Benzodiazepines clonazepam Klonopin

diazepam Valium

Succinimides ethosuximide Zarontin

methuximide Celontin

Others acetazolamide Diamox

valproic acid Depakene

zonisamide Zonegran

Drugs for treatment of partial seizures carbamazepine Tegretol, Atretol

clorazepate Tranxene

gabapentin Neurontin

Disease Spotlight: Epilepsy

Epilepsy is a collection of different syndromes, all of which is characterized by sudden discharge of

excessive electrical energy from nerve cells located within the brain. The resultant reaction is called
Nature of seizures depends on the location of the cells that initiate the electrical discharge as well as the
neural pathways which were stimulated. Seizures can be primary (no underlying cause) or secondary
(brought about by external factors like head injury).

Status epilepticus is a state in which seizures rapidly recur with no recovery between seizures. It is
potentially the most dangerous of seizures.

International Classification of Seizures categorized seizures based on symptoms and characteristics. The
two main categories include:

Generalized Seizures

These seizures are characterized by a massive electrical activity that begins in one area of the brain and
rapidly spread to both hemispheres. It is usually accompanied by loss of consciousness. It is further
classified into five types:

Tonic-clonic seizure

It involves involuntary muscle contraction (tonic) followed by relaxation appearing as an aggressive

spasm (clonic), loss of consciousness, and confusion and exhaustion in the early recovery period.

Absence seizure

It is an abrupt and brief (3-5 s) period of loss of consciousness common in children (starting at age 3) but
frequently disappears by puberty. This seizure does not usually involve muscle contractions.

Myoclonic seizure

It is characterized by short, sporadic periods of muscle contractions that last for several minutes. It is
relatively rare.

Febrile seizure

Self-limited seizure related to very high fevers and usually involves tonic-clonic seizures. This type most
frequently occurs in children.

Jacksonian Seizures

Begins in one area of the brain and involve only one part of the body but this later on spread to other
parts until a generalized tonic-clonic seizure has developed.

Partial (Focal) Seizures

These are characterized by seizures that originate from one area of the brain which do not spread to
other parts. It can be further classified into two:
Simple Partial Seizure

It occurs in a single area of the brain and may involve a single muscle movement or sensory alteration.

Complex Partial Seizure

It is a type which occurs by late teenage years and involves a series of reactions or emotional changes
and complex sensory changes (hallucinations, mental distortion, personality changes, loss of
consciousness, and loss of social inhibition). Motor changes may include involuntary urination, chewing
motions, and diarrhea.

Drugs for Treating Generalized Seizures

Drugs used for treatment of generalized seizures exert their therapeutic effects by blocking channels in
the cell membrane or by altering their receptor sites. As a result, nerve membranes become stabilized.
Their work involves the entire nervous system so sedation is an expected result.

Drugs used to treat generalized seizures include hydantoins, barbiturates, barbiturate-like drugs,
benzodiazepines, and succinimides.

Succinimides and drugs that modulate the inhibitory GABA are used to treat absence seizures.

Hydantoins

Therapeutic Action

The desired and beneficial actions of hydantoins are as follows:

Stabilize the CNS nerve membranes by decreasing the excitability and hyperexcitability of ionic channels
in the cell membrane to stimulation.

Decreasing the conduction through nerve pathways reduce the tonic-clonic, muscular, and emotional
responses to stimulation.

Indications

Hydantoins are indicated for the following medical conditions:

Control of tonic-clonic and psychomotor seizures, prevention of seizures during neurosurgery, control of
status epilepticus
Less likely to cause sedation which makes them the drug of choice for patients who are not willing to
tolerate sedation and drowsiness.

However, this class have severe adverse effects that benzodiazepines have replaced them in man
situations

Here are some important aspects to remember for indication of hydantoins in different age groups:

Children

They are more sensitive to the sedating effects of the drugs so frequent and close monitoring is
required.

Antiepileptic or antiseizure drugs can impact learning and social development.

Parents of these children should receive consistent support and education about seizure disorder and
medications.

Adults

They should receive regular care and close monitoring for adverse effects.

Adults taking this drugs are encouraged to wear MedicAlert identification during emergency instances.

Education about the disorder, lifestyle changes, medications, and handling stigma should be given focus.

Caution for use of these drugs to pregnant and lactating women is exercised because some medications
are linked to fetal abnormalities in animal studies while some are clearly associated with predictable
congenital effects in humans.

Use of barrier contraception and alternative methods for feeding are encouraged.

Stopping antiepileptic can precipitate seizures and would lead to anoxia.

Older adults

They are more susceptible to adverse effects of the drug because of possible problems in metabolism
and excretion.

There may be a need to reduce drug dosage.

Pharmacokinetics

Here are the characteristic interactions of hydantoins and the body in terms of absorption, distribution,
metabolism, and excretion:
Route Onset Peak Duration

Oral Slow 2- 12 h 6-12 h

IV 1-2 h Rapid 12-24 h

T1/2: 6-24 h

Metabolism: liver

Excretion: kidney (urine)

Contraindications and Cautions

The following are contraindications and cautions for the use of hydantoins:

Allergy to hydantoins. Prevent hypersensitivity reactions

Pregnancy, lactation. Possible problems to the fetus or the newborn.

Debilitated patients. May respond adversely to CNS depression

Impaired hepatorenal function. Interfere with drug metabolism and excretion

Coma, depression, psychoses. Can be exacerbated by the

generalized CNS depression

Adverse Effects

Use of hydantoins may result to these adverse effects:

CNS: depression, confusion, drowsiness, lethargy, fatigue

CV: arrhythmias, changes in blood pressure

GI: constipation, dry mouth, anorexia

GU: urinary retention, loss of libido

Cellular toxicity is characterized by severe liver toxicity, bone marrow suppression, gingival hyperplasia,
and serious dermatological reaction (e.g. hirsutism, Steven-Johnson syndrome).

Interactions

The following are drug-drug interactions involved in the use of hydantoins:

Alcohol: increased risk of CNS depression

Evening primrose: increased risk of seizures

Ginkgo: increased risk of serious adverse effects together with phenytoin

Barbiturates and Barbiturate-like Drugs

Therapeutic Action

The desired and beneficial action of barbiturates and barbiturate-like drugs is:

Inhibit impulse conduction in the ascending RAS, depress cerebral cortex, alter cerebral function, and
depress motor nerve input.

Indications

Barbiturates and barbiturate-like drugs are indicated for the following medical conditions:

Control of tonic-clonic and psychomotor seizures, prevention of seizures during neurosurgery, control of
status epilepticus

Similar with hydantoins, they are capable of stabilizing CNS nerve membranes by directly influencing the
ionic channels in the cell membrane resulting to decreased excitability and hyperexcitability to
stimulation.

Phenobarbital depresses lower brainstem, cerebral cortex, and motor conduction.

Aside for being used as treatment for tonic-clonic and absence seizures, mephobarbital is also used as
an anxiolytic or hypnotic agent

Here are some important aspects to remember for indication of barbiturates and barbiturate-like drugs
in different age groups:

Children

They are more sensitive to the sedating effects of the drugs so frequent and close monitoring is
required.

Antiepileptic or antiseizure drugs can impact learning and social development.

Parents of these children should receive consistent support and education about seizure disorder and
medications.

Adults

They should receive regular care and close monitoring for adverse effects.
Adults taking this drugs are encouraged to wear MedicAlert identification during emergency instances.

Education about the disorder, lifestyle changes, medications, and handling stigma should be given focus.

Pregnant women

Caution for use of these drugs to pregnant and lactating women is exercised because some medications
are linked to fetal abnormalities in animal studies while some are clearly associated with predictable
congenital effects in humans.

Use of barrier contraception and alternative methods for feeding are encouraged. Stopping antiepileptic
can precipitate seizures and would lead to anoxia.

Older adults

They are more susceptible to adverse effects of the drug because of possible problems in metabolism
and excretion.

There may be a need to reduce drug dosage.

Pharmacokinetics

Here are the characteristic interactions of barbiturates and barbiturate-like drugs and the body in terms
of absorption, distribution, metabolism, and excretion:

Route Onset Peak Duration

Oral 30-60 min N/A 10-16 h

IM, subcutaneous 10-30 min N/A 4-6 h

IV 5 min N/A 4-6 h

T1/2: 79 h

Metabolism: liver

Excretion: kidney (urine)

Contraindications and Cautions

Same with those discussed for hydantoins

Adverse Effects

CNS: depression, confusion, drowsiness, lethargy, fatigue, sedation, hypnosis, anesthesia, deep coma

CV: arrhythmias, changes in blood pressure

GI: constipation, dry mouth, anorexia

GU: urinary retention, loss of libido

Others: physical dependence, withdrawal symptoms, severe dermatological reactions

Mephobarbital is commonly associated with CNS and GI effects. It can also cause circulatory collapse
and apnea which makes it less desirable compared to other antiseizure agents.

Interactions

Alcohol: increased risk of CNS depression

Ginkgo: increased risk of serious adverse effects

Benzodiazepines

Therapeutic Action

The desired and beneficial action of benzodiazepines is as follows:

Potentiate effects of GABA (inhibitory neurotransmitter that stabilizes nerve cell membranes).

Act primarily in the limbic system and RAS so it can also cause muscle relaxation and relief of anxiety
without substantially affecting the functions of the cortex.

Indications

Benzodiazepines are indicated for the following medical conditions:

Used as adjunct to treatment of status epilepticus and severe recurrent convulsive seizures. Also used to
manage epilepsy in patients who require intermittent use to control bouts of increased seizure activity.

In addition to this, it can be used as agent to relieve anxiety before operative interventions.

Here are some important aspects to remember for indication of benzodiazepines in different age
groups:

Children

They are more sensitive to the sedating effects of the drugs so frequent and close monitoring is
required.

Antiepileptic or antiseizure drugs can impact learning and social development.

Parents of these children should receive consistent support and education about seizure disorder and
medications.

Adults
They should receive regular care and close monitoring for adverse effects.

Adults taking this drugs are encouraged to wear MedicAlert identification during emergency instances.

Education about the disorder, lifestyle changes, medications, and handling stigma should be given focus.

Pregnant women

Caution for use of these drugs to pregnant and lactating women is exercised because some medications
are linked to fetal abnormalities in animal studies while some are clearly associated with predictable
congenital effects in humans.

Use of barrier contraception and alternative methods for feeding are encouraged. Stopping antiepileptic
can precipitate seizures and would lead to anoxia.

Older adults

They are more susceptible to adverse effects of the drug because of possible problems in metabolism
and excretion.

There may be a need to reduce drug dosage.

Pharmacokinetics

Here are the characteristic interactions of benzodiazepines and the body in terms of absorption,
distribution, metabolism, and excretion:

Route Onset Peak Duration

Oral 30-60 min 1-2 h 3h

IM 15-30 min 30-45 min 3h

IV 1-5 min 30 min 15-60 min

Rectal Rapid 1.5 h 3h

T1/2: 20-80 h

Metabolism: liver

Excretion: kidney (urine)

Contraindications and Cautions

The following are contraindications and cautions for the use of benzodiazepines:
Same with those discussed for hydantoins

Adverse Effects

Use of benzodiazepines may result to these adverse effects:

CNS: depression, confusion, drowsiness, lethargy, fatigue,

CV: arrhythmias, changes in blood pressure

GI: constipation, dry mouth, anorexia

GU: urinary retention, loss of libido

Others: physical dependence, withdrawal symptoms

Succinimides

Therapeutic Action

The desired and beneficial action of succinimides is as follows:

Act in inhibitory neuronal systems and suppress the electroencephalographic pattern associated with
absence seizures.

Indications

Succinimides are indicated for the following medical conditions:

Most frequently used to treat absence seizures and reduction of frequency of attacks

Here are some important aspects to remember for indication of succinimides in different age groups:

Children

They are more sensitive to the sedating effects of the drugs so frequent and close monitoring is
required.

Antiepileptic or antiseizure drugs can impact learning and social development.

Parents of these children should receive consistent support and education about seizure disorder and
medications.

Adults

They should receive regular care and close monitoring for adverse effects.

Adults taking these drugs are encouraged to wear MedicAlert identification during emergency instances.

Education about the disorder, lifestyle changes, medications, and handling stigma should be given focus.
Stopping antiepileptic can precipitate seizures and would lead to anoxia.

Use of barrier contraception and alternative methods for feeding are encouraged.

Pregnant women

Caution for use of these drugs to pregnant and lactating women is exercised because some medications
are linked to fetal abnormalities in animal studies while some are clearly associated with predictable
congenital effects in humans.

Older adults

They are more susceptible to adverse effects of the drug because of possible problems in metabolism
and excretion.

There may be a need to reduce drug dosage.

Pharmacokinetics

Here are the characteristic interactions of succinimides and the body in terms of absorption,
distribution, metabolism, and excretion:

Route Onset Peak Duration

Oral N/A 3-7 h N/A

T1/2: 30 h (children), 60 h (adults)

Metabolism: liver

Excretion: kidney (urine), liver (bile)

Contraindications and Cautions

The following are contraindications and cautions for the use of succinimides:

Same with those discussed for hydantoins

Adverse Effects

Use of succinimides may result to these adverse effects:

CNS: depression, drowsiness, fatigue, ataxia, insomnia, headache, blurred vision

GI: decreased GI activity, nausea, vomiting, anorexia, weight loss, GI pain, constipation or diarrhea
Direct chemical irritation of the skin and bone marrow: bone marrow suppression, fatal pancytopenia,
urticarial, alopecia, Steven-Johnson’s syndrome

Ethosuximide has relatively few adverse effects compared with may antiseizure agents.

Interactions

The following are drug-drug interactions involved in the use of succinimides:

Primidone: decreased primidone serum levels

Drugs for Treating Partial Seizures

Partial seizures can be either simple (single muscle or reaction) or complex (series of reactions or
emotional changes).

Therapeutic Action

The desired and beneficial actions of drugs used for treatment of partial seizures are as follows:

Drugs used to control partial seizures stabilize nerve membranes either by altering sodium and calcium
channels or by increasing the activity of inhibitory neurotransmitter GABA.

Carbamazepine inhibits polysynaptic responses and blocks sodium channels to prevent formation of
repetitive action potentials. It is chemically related to TCAs.

Clorazepate and felbamate potentiate the effects of GABA.

Gabapentin blocks polysynaptic responses and stimulus increases in certain situations.

Indications

Drugs used for treatment of partial seizures are indicated for the following medical conditions:

Carbamazepine, felbamate, and oxcarbazepine are used as monotherapy. The remaining drugs are used
as adjunctive therapy.

Pharmacokinetics

Here are the characteristic interactions of drugs used for treatment of partial seizures and the body in
terms of absorption, distribution, metabolism, and excretion:

Drugs Onset Peak Duration T 1/2 Metabolism and Excretion

Carbamazepine (oral) N/A N/A N/A 25-65 h Liver, kidney (urine)

Clorazepate (oral) Rapid 1-2 h N/A 30-100 h Liver, kidney (urine)

Gabapentin (oral) N/A N/A N/A 5-7 h N/A, kidney (urine; unchanged_
Contraindications and Cautions

The following are contraindications and cautions for the use of drugs indicated for treatment of partial
seizures:

Allergy to antiseizure agents. Prevent hypersensitivity reactions

Bone marrow suppression. Exacerbated by drug effects.

Severe hepatic dysfunction. Interferes with drug metabolism

Pregnancy. Carbamazepine, clorazepate, and gabapentin have been shown dangerous to fetus

Renal stones. Can be exacerbated by drug effects

Adverse Effects

Use of drugs indicated for treatment of partial seizures may result to these adverse effects:

CNS: drowsiness, fatigue, weakness, confusion, headache, insomnia

Respiratory: upper respiratory infections

GI: GI depression, nausea, vomiting, anorexia

Pregabalin is a category V controlled substance (can cause feelings of well-being and euphoria). It is also
related to CNS depression characterized by somnolence, dizziness, and visual changes.

Interactions

The following are drug-drug interactions involved in the use of drugs indicated for treatment of partial
seizures:

Other CNS depressants, alcohol: increased risk of CNS depression

Nursing Considerations

Here are important nursing considerations when administering this drug:

Nursing Assessment

These are the important things the nurse should include in conducting assessment, history taking, and
examination:

Assess for mentioned contraindications and cautions (e.g. drug allergy, diabetes, hepatorenal
dysfunction, arrhythmias, hypotension, etc.) to prevent untoward complications.

Assess for the description (onset, aura, duration, recovery) of seizures to determine type of seizure and
establish a baseline.
Perform a thorough physical assessment (skin color and lesions, vital signs, level of orientation, affect,
reflexes, bowel sounds, urine output, etc.) to obtain baseline data and monitor changes associated with
adverse effects.

Monitor results of laboratory tests (renal and liver function) to determine appropriateness of therapy
and possibility of dose adjustment.

Nursing Diagnoses

Here are some of the nursing diagnoses that can be formulated in the use of this drug for therapy:

Acute discomfort related to GI, CNS, and GU effect

Disturbed thought processes related to CNS effects

Impaired skin integrity related to dermatological effects

Risk for infection relatedto bone marrow suppression

Risk for injury related to CNS effects and toxic drug levels

Implementation with Rationale

These are vital nursing interventions done in patients who are antiseizure agents:

Monitor for adverse effects and provide appropriate supportive care as needed to help patient cope
with these effects.

Monitor CBC results to detect bone marrow suppression early and provide prompt intervention.

Discontinue the drug at any sign of hypersensitivity reaction, liver dysfunction, and severe skin rash to
limit reaction and prevent potentially serious reactions.

Provide comfort measures (e.g. positioning of legs and arms for dyskinesia, sugarless candy and ice chips
for dry mouth, voiding before taking drugs for urinary hesitancy or retention, etc.) to help patient
tolerate drug effects.

Provide safety measures (e.g. adequate lighting, raised side rails, etc.) to prevent injuries.

Educate client on drug therapy to promote understanding and compliance

.Evaluation

Here are aspects of care that should be evaluated to determine effectiveness of drug therapy:

Monitor patient response to therapy (decrease in incidence or absence of seizures).

Monitor for adverse effects (e.g. CNS changes, GI depression, bone marrow suppression, severe
dermatological reactions, liver toxicity, etc).
Evaluate patient understanding on drug therapy by asking patient to name the drug, its indication, and
adverse effects to watch for.

Monitor patient compliance to drug therapy.