Treatment
Although some clinicians prescribe anti-seizure medication for patients with acute symptomatic seizures, we do not recommend primary or secondary prophylaxis for such seizures.
However, such medications should be considered for treating late seizures. If the seizures are seldom and not particularly problematic, medication is not always needed, but in the vast majority of cases, it is appropriate to initiate treatment.
When choosing medication for this patient group, numerous factors need to be considered. Many older patients have impaired liver and kidney function as well as low levels of serum albumin, which necessitates a low dosage rate and low initial target dose. The reference ranges for these medications are not as valid for this patient group as for younger adults.
Although there are no fundamental differences in seizure-reducing effect between the old and new medications, the results of clinical trials favour the new ones (21), mainly due to better tolerance and a lower risk of drug interactions. The latter is particularly important in older patients given the high prevalence of multimorbidity.
The choice of medication should be tailored to the individual, taking account of age, sex, weight, co-morbidity and other treatment. Lamotrigine, levetiracetam and lacosamide are the preferred medications for this patient group (22, 23). Valproate can also be a good alternative, but not as a first choice in our opinion. Table 1 shows the initial dose, dose escalation rate, initial target dose and the most common adverse effects of these medications. Further dosing depends on efficacy and adverse effects.
Table 1
Suggested medications for post-stroke epilepsy, including initial doses, dose escalation rates, initial target doses and the most common adverse effects. The suggestions are based on our own clinical experience.
| Medication | Initial dose | Dose escalation rate | Initial target dose | Common adverse effects |
|---|
| Lamotrigine | 25 mg daily
(monodose) | Up-titrate with 25 mg daily every 2 weeks (monodose) | 100 mg daily
(monodose)1 | Skin rash, insomnia, headache |
| Levetiracetam | 500 mg daily
(250 mg × 2) | Up-titrate to 1000 mg daily after 2 weeks | 1000 mg daily
(500 mg × 2) | Fatigue, irritability |
| Lacosamide | 50 mg daily | Up-titrate to 100 mg daily after 1 week | 100 mg daily
(50 mg × 2) | Fatigue, dizziness |
Old liver enzyme-inducing drugs such as carbamazepine, phenytoin and phenobarbital are best avoided for this patient group as they can cause numerous pharmacokinetic drug interactions and have a tendency to increase markers of vascular risk and lead to bone loss (24, 25). Oxcarbazepine, which is a less potent enzyme inducer than carbamazepine, should also be avoided due to its tendency to cause hyponatraemia, particularly in older patients (26).
Initial follow-up should entail frequent outpatient check-ups. Blood analyses should be performed in cases of inefficacy or suspected adverse effects, drug interactions or poor treatment adherence. If the patient stops having seizures and has no problematic adverse effects, annual check-ups with a neurologist or general practitioner will suffice.