Seizure management in a complex hospice patient

Area of Science:

• Palliative Care Medicine
• Clinical Pharmacy
• Neurology

Background:

• Antiepileptic medication use in non-cancer hospice and palliative care settings lacks clear guidelines.
• Managing seizures in patients with advanced diseases presents unique challenges, including drug interactions and altered pharmacokinetics.
• Human immunodeficiency virus (HIV) disease can complicate seizure management due to comorbidities and potential drug interactions.

Observation:

• A 22-year-old female with advanced HIV experienced increased tonic-clonic seizure frequency despite oral phenytoin therapy.
• The patient also had hypoalbuminemia, gastroesophageal reflux disease (GERD), and gastritis, which could affect drug metabolism and efficacy.
• Seizure frequency escalated during her inpatient hospice admission, necessitating a medication regimen review.

Findings:

• A collaborative approach between clinical pharmacists and physicians led to medication regimen simplification.
• Discontinuation of oral phenytoin and initiation of oral levetiracetam resulted in a significant decrease in seizure frequency.
• This intervention highlights the successful adjustment of antiepileptic therapy in a complex patient population.

Implications:

• Case demonstrates the critical need for individualized anticonvulsant selection and monitoring in advanced illness.
• Highlights potential challenges such as drug-drug interactions, altered pharmacokinetics, and increased adverse effect risks in hospice patients.
• Emphasizes the importance of pharmacist-physician collaboration for optimizing medication management and patient outcomes in palliative care.