Drug withdrawal in the epilepsy monitoring unit – The patsalos table

• Published in: Seizure (London, England) England), 2020-02, Vol.75, p.75-81
• Main Authors: Kirby, Jack, Leach, Veronica M, Brockington, Alice, Patsalos, Phillip, Reuber, Markus, Leach, John Paul
• Format: Article
• Language: English
• ISSN: 1059-1311; 1532-2688
• DOI: 10.1016/j.seizure.2019.12.010

•Investigating refractory epilepsy requires considering risk of induced seizures.•We present our opinion on enhancing the safety of drug manipulation in epilepsy monitoring units.•Manipulating drugs requires consideration of AED pharmacokinetics drug-drug interactions.•We have provided a table listing the properties of individual AEDs named The Patsalos Table. Investigation of possible candidates for epilepsy surgery will usually require inpatient EEG to capture seizures and allow full operative planning. Withdrawal of antiepileptic drugs increases the yield of this valuable diagnostic information and the benefits of this should justify any increase in the risk of harm associated with these seizures This paper outlines our opinion on what would constitute proposed best practice for management of antiepileptic drug (AED) dosing when patients are admitted for monitoring of seizures to an epilepsy monitoring unit (EMU). In the vast majority of cases EMU admissions are safe and, even if seizures occur, will pass off without complication. Previous guidance has concentrated on ensuring practice around technical aspects of EEG monitoring itself and staffing within the unit. In this guidance we aim to outline optimally safe ways of ensuring that EMUs ensure the minimisation of risk to the patients admitted under their care. We propose an algorithm for enhancing the safety of AED withdrawal in VT admissions while ensuring adequate seizure yields. Risk minimisation requires planned management of drug dosing (with reduction if appropriate), provision of adequate rescue medication, and adequate supervision to allow rapid response to generalised seizures. This algorithm is accompanied by a table which uses knowledge of the clinical and pharmacological properties of each AED to ensure dose withdrawal and reduction is timely and safe taking into account the severity and frequency of the individual’s seizures.