JPPT Case Report Enteral Topiramate in a Pediatric Patient with Refractory Status Epilepticus: A Case Report and Review of the Literature Chasity M. Shelton, PharmD,1 Elizabeth L. Alford, PharmD,1 Stephanie Storgion, MD,2 James Wheless, MD,2,3 and Stephanie J. Phelps, PharmD1,2 1 Department of Clinical Pharmacy, College of Pharmacy, and 2Department of Pediatrics, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee; 3Neuroscience Institute and Le Bonheur Comprehensive Epilepsy Program, Le Bonheur Children’s Hospital, Memphis, Tennessee
We describe the use of topiramate in a healthy 12-year-old (88-kg) male who developed refractory generalized convulsive status epilepticus. Seizures persisted despite aggressive use of benzodiazepines (intravenous lorazepam; oral clorazepate), barbiturates (i.e., phenobarbital, pentobarbital), and hydantoins. The child’s seizures were controlled with nasogastrically administered topiramate in doses up to 500 mg twice daily (11.4 mg/kg/day). The patient did not display any clinical or laboratory signs of metabolic acidosis while receiving topiramate. Topiramate should be considered as a treatment option in refractory status epilepticus. INDEX TERMS: epilepsy, pediatric, refractory status epilepticus, topiramate, treatment J Pediatr Pharmacol Ther 2014;19(4):317–324
INTRODUCTION Refractory generalized convulsive status epilepticus occurs when seizures persist despite adequate doses of first-line benzodiazepines (midazolam, lorazepam or diazepam) and second-line antiepileptic drugs (phenytoin/fosphenytoin, phenobarbital, or valproate).1,2 It is imperative that clinical and electrical seizure activity is terminated as soon as possible as the risk of mortality significantly increases with increased seizure duration.3–5 The severest cases frequently require admission to the intensive care unit and use of intravenous (IV) or nasogastrically administered anticonvulsants or general anesthesia. Although there is no commercially available IV formulation of topiramate, it can be administered enterally, making it suitable for the treatment of refractory status epilepticus. We describe a case involving the successful use of enterally administered topiramate in a pediatric patient whose generalized convulsions were refractory to benzodiazepines, barbiturates, and hydantoin.
CASE REPORT A 12-year-old male, weighing 88 kg, was seen J Pediatr Pharmacol Ther 2014 Vol. 19 No. 4 • www.jppt.org
in the emergency department with new onset generalized convulsive seizures. Medical history was insignificant except for a “flu-like illness” during the previous month and cold symptoms 5 days prior to admission. He complained of a headache accompanied by nausea and vomiting and was noted to have a temperature of 38.9°C. The patient received a diagnosis of viral illness and was discharged home. Several days later, while watching a live, outdoor football game in which he was scheduled to play, the child became unresponsive, went “limp,” and had facial twitching and whole-body jerking that lasted approximately 3 to 5 minutes. He was noted to foam at the mouth but had no urinary incontinence. He was post-ictal when the ambulance arrived at the emergency department. In the emergency department, the child developed generalized stiffening, his eyes were deviated to the right, and opisthotonic posturing lasted 2 to 3 minutes. He was unresponsive to voice commands and pain. Family history was negative, with the exception of maternal seizure history as a child. Clinical seizures stopped after the IV administration of lorazepam, 8 mg (0.1 mg/kg), and fosphenytoin, 1000 mg phenytoin equivalents 317
JPPT (PE). A comprehensive metabolic panel revealed normal laboratory results, except for a slightly decreased serum potassium concentration (3.2 mEq/L). Results of complete blood count analysis with differential were also normal. Urine drug screen findings were negative. Vital signs were as follows: temperature 37.5°C; heart rate, 92 beats/min; respiratory rate, 20 breaths/min; and blood pressure, 137/80 mm Hg. A short period of time after the seizures stopped, he was alert and oriented with a Glasgow coma scale score of 15. Imaging results of computed tomography without contrast of the head were normal. The child was admitted to the medicine service with the diagnosis of generalized tonic-clonic seizures and possible viral encephalitis. Later on the day of admission, the patient’s seizures recurred, lasting for
We describe the use of topiramate in a healthy 12-year-old (88-kg) male who developed refractory generalized convulsive status epilepticus. Seizures persisted despite aggressive use of benzodiazepines (intravenous lorazepam; oral clorazepate), barbiturates (i.e., phenobarbital, pentobarbital), and hydantoins. The child’s seizures were controlled with nasogastrically administered topiramate in doses up to 500 mg twice daily (11.4 mg/kg/day). The patient did not display any clinical or laboratory signs of metabolic acidosis while receiving topiramate. Topiramate should be considered as a treatment option in refractory status epilepticus. INDEX TERMS: epilepsy, pediatric, refractory status epilepticus, topiramate, treatment J Pediatr Pharmacol Ther 2014;19(4):317–324
INTRODUCTION Refractory generalized convulsive status epilepticus occurs when seizures persist despite adequate doses of first-line benzodiazepines (midazolam, lorazepam or diazepam) and second-line antiepileptic drugs (phenytoin/fosphenytoin, phenobarbital, or valproate).1,2 It is imperative that clinical and electrical seizure activity is terminated as soon as possible as the risk of mortality significantly increases with increased seizure duration.3–5 The severest cases frequently require admission to the intensive care unit and use of intravenous (IV) or nasogastrically administered anticonvulsants or general anesthesia. Although there is no commercially available IV formulation of topiramate, it can be administered enterally, making it suitable for the treatment of refractory status epilepticus. We describe a case involving the successful use of enterally administered topiramate in a pediatric patient whose generalized convulsions were refractory to benzodiazepines, barbiturates, and hydantoin.
CASE REPORT A 12-year-old male, weighing 88 kg, was seen J Pediatr Pharmacol Ther 2014 Vol. 19 No. 4 • www.jppt.org
in the emergency department with new onset generalized convulsive seizures. Medical history was insignificant except for a “flu-like illness” during the previous month and cold symptoms 5 days prior to admission. He complained of a headache accompanied by nausea and vomiting and was noted to have a temperature of 38.9°C. The patient received a diagnosis of viral illness and was discharged home. Several days later, while watching a live, outdoor football game in which he was scheduled to play, the child became unresponsive, went “limp,” and had facial twitching and whole-body jerking that lasted approximately 3 to 5 minutes. He was noted to foam at the mouth but had no urinary incontinence. He was post-ictal when the ambulance arrived at the emergency department. In the emergency department, the child developed generalized stiffening, his eyes were deviated to the right, and opisthotonic posturing lasted 2 to 3 minutes. He was unresponsive to voice commands and pain. Family history was negative, with the exception of maternal seizure history as a child. Clinical seizures stopped after the IV administration of lorazepam, 8 mg (0.1 mg/kg), and fosphenytoin, 1000 mg phenytoin equivalents 317
JPPT (PE). A comprehensive metabolic panel revealed normal laboratory results, except for a slightly decreased serum potassium concentration (3.2 mEq/L). Results of complete blood count analysis with differential were also normal. Urine drug screen findings were negative. Vital signs were as follows: temperature 37.5°C; heart rate, 92 beats/min; respiratory rate, 20 breaths/min; and blood pressure, 137/80 mm Hg. A short period of time after the seizures stopped, he was alert and oriented with a Glasgow coma scale score of 15. Imaging results of computed tomography without contrast of the head were normal. The child was admitted to the medicine service with the diagnosis of generalized tonic-clonic seizures and possible viral encephalitis. Later on the day of admission, the patient’s seizures recurred, lasting for
