Therapeutic Considerations of Antiseizure Medications-Special Situations: Surgery/NPO, Illness, and What to do When Dose is Missed

Video Transcription

All right, so my name is Shivani Botninger, and I am a nurse practitioner in the EMU at Nationwide Children's Hospital. And I'm going to be talking to you about special scenarios  in which you may need to advise patients to take medications differently or alter their antiseizure medication plans.  So disclosures to start off. I did want to mention that I do include some information in the presentation that talks about some off-label uses.  And some of the content that I'm going to present to you will be practices that are reflected from multiple institutions. And so I will just recommend that if you're  in a situation where you're making medication changes or have alterations in a medication plan to consult a pharmacist before making those changes,  if you have questions or concerns.  So learning objectives. I hope that by the end of the presentation today, you guys will be able to formulate a plan for antiseizure medications  in special situations, looking at appropriately selecting alternative antiseizure medications when patients are NPO for procedures, or if they're not  able to tolerate oral medications following a procedure, and then any recommendations about appropriate antiseizure medications and other scenarios you may come across.  So to start off, the first thing that I want to talk about was missed medication doses. And we see this all across the lifespan, pediatric patients, adult patients.  We often see it in our teenage patients that just either don't set reminders or will not take their medication. And so we can get phone calls about, what do I do?  I missed a dose of medication. And this is probably something that you all who work in the outpatient world experience a lot more than the inpatient world on the EMU.  But typically, the rule of thumb that we use is that as long as it's been less than half the time between the full amount of time between two doses,  you would advise the family or the patient to go ahead and take the medication. So for BID dosing, if you're taking it once every 12 hours, you realize there's a missed medication.  If it's been less than six hours, it's OK to go ahead and take that medication. So take that missed dose, and then continue like you were scheduled to take medications.  For Q-day dosing, same thing. If it's been less than 12 hours, you can go ahead and advise the patient to take that missed dose and then continue with the next dose as well.  These recommendations, again, can be applied the same time frame for QID and TID dosing as well. And there are some medications that might be a little bit different just  based on the pharmacokinetics of the medication and the dosage form. So some of the newer medications, you may have to look a little bit more  and get some input from maybe a pharmacist to better plan for this.  So another thing, again, we often see this in the pediatric population, but I'm sure it does happen in the adult world as well. Well, kids are sick often.  They go to school, go to daycare. They're picking up bugs. And we'll get phone calls, oh, Sally vomited all of her medications this morning. Should I give her a dose?  Should I wait till the next one? And families are worried about maybe giving too much of a medication. And so this is something that we're commonly seeing.  And this is kind of a summary or rule of thumb that we use is if they have vomited within 15 minutes of receiving that medication, you can go ahead and re-dose that full dose.  It's helpful. In some cases, you may see, you can ask families if they're calling in, or the patient, if they saw the pill in the vomit.  Or if it's liquid, it kind of gets a little bit harder to determine if all the medication came up, if anything at all did. So if it's less than 15 minutes after the dose was given,  you can re-dose it. If it is greater than 15 minutes after the dose, you don't want to re-dose it. Because by that point, there's some medication that's been absorbed.  And we don't have any way of determining how much medication was absorbed. And we don't want to run the risk of giving too much medication.  So we just want to make sure we continue with that next dose as scheduled. If the child or patient vomits again after the re-dose of the medication,  we would not re-dose for a second time. If there's one vomit episode and we re-dose the medication and the patient vomits again, you  would hold off and just continue with that next scheduled dose. And again, because at that point, we don't know how much of the medication's been absorbed.  And we don't want to end up with the patient having more medication than needed.  I included the ketogenic diet in here. I know it's not technically a medication.  When we're educating families and patients that are on the diet, we treat it as a medication. We're titrating the dose. We're monitoring labs.  And it's something that needs to be closely followed. And again, if you're sick on the ketogenic diet, there are things that we want to keep in mind.  Of course, our primary goal with a ketogenic diet is to make sure that we're maintaining ketosis, especially if that's helping with seizure control.  But in the case of illness or situations of dehydration resulting from illness, we want to make sure that our patients are taken care of. And sometimes that means that we have  to give them medications that bring them out of ketosis. And that's acceptable. We'll just have to work on getting them back into ketosis. So the goal with this is when patients  are ill while they're on the ketogenic diet, we can see an excess amount of ketosis. And we want to make sure that we're not getting to that point, especially with dehydration.  And in patients who are on the ketogenic diet, you have to eat and drink very specific amounts of food. A lot of times, your food is weighed. And if you're not able to consume that,  it affects the ratio that you're getting and can result in fluctuation in ketosis level. And so if the patient is dehydrated or vomiting,  the goal is to make sure that we're rehydrating. So rehydration is more important than maintaining ketosis when a patient is ill.  So a lot of times, we'll have calls from families asking, what can we do? We're not able to. A little Charlie has started the keto.  They were doing great, but isn't able to keep anything down. They're really dehydrated. Do we bring them in to the hospital for monitoring? What are the next steps?  And so educating the families and patients that our goal is to make sure that the patient overall is well taken care of.  And if we come out of ketosis, essentially like a missed dose, we can get them back on track once they're feeling better.  So we can adjust their dosing or their diet plan moving forward.  And then when patients are NPO status for procedures, and this is something that we often see on the EMU inpatient and even outside of epilepsy management,  patients have different procedures that they're going to. And we want to make sure that they're getting the appropriate medications if needed.  So for patients who are on anti-seizure medications and NPO for procedure, it's important that we want to consider the impact of missed medications.  Typically, anti-seizure medications are on the list of medications that we want to make sure are given for certain procedures to avoid seizures.  And so we can give many of the medications with small sips of water. And again, this is very dependent on the institution and the anesthesiologist and the provider  and also the procedure that's being done. But for the most part, at least our institution, we tend to give anti-seizure medications, again, because we want to avoid having seizures  while we're down in procedures. In situations where patients are NPO because they're not tolerating oral medications, and that can be because they're post-op,  they've had a procedure, maybe they're too sedated to safely take medication without aspiration, we have to consider giving medications through a different route.  And so sometimes that means changing from an oral formulation to something that's IV or given through an NG tube. And so for patients who are on extended release medications  or on medications that don't have a liquid formulation, we have to really consider what other alternatives we can do.  And so in this case, if there are medications that can be crushed, you would crush them and administer them through an NG tube if necessary.  For extended release, you can take that medication and switch it to an immediate release dosage form, whether that be liquid or tablet, and then adjust the dosing.  So you would take that 24-hour or daily dosing and divide it into BID or TID dosing, depending on the medication and the formulation that you're using.  And then, again, if a patient is NPO for an extended period of time, so an example that comes to mind just from our practice within our institution is oftentimes  our patients who have corpus callosotomies or hemisrectomies are very sleepy for quite a while after surgery. And that can be up to a week before they're  able to start taking medications by mouth like they would have prior to. And so they oftentimes end up with an NG tube. And if maybe they're not tolerating that,  we will consider switching to IV medications, especially if they're having vomiting and they're not able to keep that medication down. So there's definitely options.  Not every medication we have, as you guys know, has a oral and an IV formulation. So there's some charts that I'll show you guys here in a bit that will go over just some options  that you can use in the case that you were to run into a situation like that. So this one here, so the most common one that I think of  is we have a lot of patients that are on Keppra. And we do have a liquid formulation of Keppra. And there's tablets. But and then we also have the IV form.  So that's an easy one where we know we have all different formulations. But there's Breviac, which is not something and Breviracetam is one that we don't have an IV equivalent.  And so we would use Keppra or Levatoracetam instead. Same with Clobazam. We can use IV lorazepam. And I have the dosing listed here. So there are several different medications  that we would want to consider using a different medication maybe that's in the same mechanism of action to ensure that the patient is still covered as far  as seizure control without putting them at risk for aspiration or continued dehydration and vomiting.  And again, this is a list. And this is not an exhaustive list of all of our medications. These are ones that we commonly see with different formulations.  So these are ones that have enteral formulations that we can use, whether it's tablet or oral solution, liquid formulations to help make changes to the plan  if we need to ensure that our patients are receiving the medications while also meeting the requirements if they need to be NPO or with sedation. And then, like I mentioned, there's  a couple of medications that we come across that don't have the IV or alternative to their enteral forms. And so the two that I mentioned, again,  was the Breviracetam and the Clobazam. So instead of using Clobazam if they can't take anything by mouth or through a tube, we could do Clonazepam. And there's the dosing there.  So 0.5 milligrams of Clonazepam for every 10 milligrams of Clobazam with a max of 3 milligrams per day. So we can make some adjustments to meet the needs of our patients.  So just kind of to summarize, miss medication doses. Rule of thumb is that if it's been less than half the time between the two doses, go ahead and take the medication.  If it's more than half the time, skip that dose that was missed and resume your typical medication routine starting with the next dose. With procedures, most of the time  you're advising patients to make sure that you're taking all of their anti-seizure medications. And again, there are certain situations,  depending on the procedure, that might be different. But generally, you're advising patients to take their anti-seizure medications prior to their procedure.  We can make adjustments taking a dose a little bit earlier than typical to make sure they're following their NPO guidelines. And we can also switch to IV formulations  if we're not tolerating PO medications, post-procedure, or anesthesia. And then with the ketogenic diet, rehydration during illness is more important than maintaining ketosis.  So we try our best to maintain ketosis. But in cases of illness, making sure we're staying hydrated and then monitoring for excessive ketosis, because we don't want patients  to start experiencing the negative side effects that come along with the excessive ketosis.  Thank you.

Video Summary

Shivani Botninger, a nurse practitioner at Nationwide Children's Hospital, discusses special scenarios for adjusting antiseizure medication plans. Key points include handling missed doses, where patients can take a missed dose if it's less than half the time to the next scheduled dose. Vomiting situations allow a re-dose if vomiting occurs within 15 minutes. Managing antiseizure medications with the ketogenic diet emphasizes hydration over ketosis during illness. For patients NPO for procedures, alternative routes like IV or NG tubes may be used. Recommendations include consulting pharmacists for medication plan changes when necessary.

Asset Subtitle

Presenter:

Shivani Bhatnagar, DNP, RN, CPN, CPNP-PC, has been a pediatric nurse for 11 years, 4 years as a bedside nurse in general pediatrics and 7 years are an APRN with Neurology, at Nationwide Children's Hospital in Columbus, OH. She has been an Assistant Professor of Clinical Practice at The Ohio State University College of Nursing since 2018. Her Doctor of Nursing Practice Degree final scholarly project focused on continuing education for bedside nurses caring for patients with epilepsy.
◦LinkedIn: https://www.linkedin.com/in/shivani-bhatnagar-aprn

Keywords

antiseizure medication

missed doses

ketogenic diet

alternative routes

pharmacist consultation