Abstracts

Rationale: Epilepsy clinics include patients with documented epilepsy as well as those with seizure-like activity lacking clear diagnosis.  Rescue medications may be prescribed for either type for a seizure management plan to abort prolonged or clusters of seizures, but require careful patient education on frequency and situations for use, precautions and risks. Prescribed rescue medications are almost universally benzodiazepines (BDZ), but in many instances are not FDA approved for this indication.  Currently, there are only three US marketed, FDA approved seizure rescue medications: rectal diazepam (Diastat), intranasal midazolam (Nayzilam), and intranasal diazepam (Valtoco).  Prescription directions for both FDA and non-FDA approved rescue agents may vary not only as written, but also how interpreted by patients. BDZ prescribed for other indications may be used by patients for seizure rescue. These complex practices can result in misuse, overuse, and underuse of these rescue medications

Methods: This is a retrospective study of patients in the adult epilepsy clinic at Atrium Health Wake Forest Baptist. We reviewed the patients seen in the epilepsy clinic between January and and May 2023. Data recorded included demographic information, whether there was a known seizure diagnosis, and whether there was a history of seizure clusters or prolonged seizures. We also recorded maintenance seizure treatment plan (antiseizure medications, neurostimulation, epilepsy surgery, and diet) as well as rescue seizure plan as documented in the patient record. Specific prescribed directions for BDZ used for rescue and for other indications were documented, as well as patient reported use. Originating source of prescription and amount of completed BDZ refills during the study time were also recorded.

Results: We found that one third of patients were prescribed at least one BDZ for seizure rescue. Half of these prescriptions were for unapproved seizure rescue medications, most frequently lorazepam (oral or sublingual) and clonazepam (oral). Of those receiving FDA approved rescue agents, the majority received Nayzilam, less frequently Diastat, then Valtoco.  Few patients had documentation of rescue medication use.  Directions prescribed were highly variable, but most consistent for the FDA-approved seizure rescue medications. Thirty percent of prescriptions for rescue originated outside the epilepsy clinic and were equally distributed between FDA and non-FDA approved rescue agents.

Conclusions: BDZ for seizure rescue are widely used in the adult epilepsy population, often originally prescribed by providers outside the epilepsy clinic. Non-FDA approved rescue medications are often prescribed, and prescribing directions frequently are without specific instruction of when and how often to use. Documentation of use and lack of use is often lacking in the electronic medical record. This indicates a need for improved documentation of directions for the rescue seizure management plan, and patient education of this plan. In addition to reviewing seizure frequency, instances of rescue medication use and efficacy should be reviewed and documented to ensure optimal use.

Funding: None