Abstracts

Rationale: Before epilepsy center referral, benzodiazepines (BDZ) are frequently prescribed to outpatients for nonepilepsy use and as seizure abortives “pro re nata” (prn). The prn dosing of prescribed BDZs is at the patient’s discretion, and pill counts and careful histories can reveal inappropriate and excessive use.    Although BDZ may be prescribed for anxiety, patients commonly misconstrue these medications as part of their antiepilepsy drug (AED) regimen. Further overuse and potential tolerance may result with subsequent inefficacy, as well as interference with EEG testing. Methods: We reviewed 500 adult outpatient charts on referral to the epilepsy clinic at Wake Forest University Comprehensive Epilepsy Center from 1/2015- 1/2018.  We reviewed referral source (primary care, emergency, neurologist or other, as well as self referral), patient age and sex, number of AEDs, number of and routes of active  BDZ prescriptions, and  reasons for  their use (if stated on prescription).  Clobazam was considered as AED in this data. Results: One hundred forty-four of the 500 charts listed BDZs in prescription profiles. Age range of patients prescribed BDZ was 18-85.   Sixty-two of the 144 indicated at least one BDZ was specifically prescribed “prn” for seizures.  Ninety-eight charts indicated prescription of two or more benzodiazepines, not necessarily all for prn use..   The remainder had oral BDZ prescribed only due to reasons that were either not specified or specified for nonepilepsy uses.  More females than males were on multiple BDZ, but similar numbers of males and females were prescribed BDZ overall or prn. Conclusions: BDZ are commonly prescribed by physicians treating patient prior to epilepsy center referral. This can create difficulty in determining diagnosis, as BDZs affect the EEG, and can influence treatment by increasing the complexity of weaning and titrating regimens. The well-established utility of abortive BDZ is limited to specific BDZ with adequate mucosal absorption and parenteral formulations.   The common practice of prescribing prn  oral BDZs may provide reduction in anxiety and prophylaxis for nonacute seizures, but has no established acute seizure benefit.  The  careful epileptologist is faced with a difficult scenario with such referrals, and may earn a dreaded "low patient satisfaction" rating simply for trying to wean a patient off unnecessary and potentially harmful BDZ. We recommend careful history of how a patient decides when to self-medicate for seizures, and to ascertain that BDZ are used appropriately.  We also recommend, advising for involvement of behavioral health to help manage uncontrolled anxiety, and avoiding poly-BDZ therapy when possible. Further study is needed to determine how proactive changes to referral processes, tele-epilepsy consults, and multidisciplinary clinics might optimize appropriate use of outpatient BDZ in the epilepsy population. Funding: Not applicable