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175 Seizure management in patients unable to take oral medications: a multi-centre audit

Background Seizures are common in the palliative care population. For patients who are unable to take oral medication, seizure management can become problematic but there is little consensus on best practice, particularly for patients with longer prognoses. Aim To examine prescribing of non-oral and 'as required' anticonvulsant medication across multiple palliative settings (community/hospice/acute hospital). Method A regional multi-centre audit of prescribing practice was conducted from October to December 2017. Inclusion criteria: adult patients requiring anticonvulsant medication but unable to take oral preparations. Practice was assessed against regional Palliative Care guidelines. Data was collected retrospectively via a SmartSurvey proforma. Results Twenty-six patients across six centres were included. When unable to take oral medications, 25 patients (96%) commenced a continuous subcutaneous infusion (CSCI). Fourteen patients were prescribed levetiracetam (250 mg-3 g/24 hours), seven were prescribed midazolam (15–30 mg/24 hours), two were prescribed sodium valproate (600 mg/24 hours) and two were prescribed combination levetiracetam (3 g) and midazolam (30–40 mg). One patient had no regular anticonvulsant as they were imminently dying. Where prognosis was estimated, 80% of patients commencing a midazolam CSCI were felt likely to survive less than a week Seizures were controlled in 69% of patients with initial doses prescribed. 'As required' anticonvulsant medication was prescribed for 23 patients (88%); all were prescribed subcutaneous midazolam (2.5 mg-10 mg). Phenobarbital (8 patients), buccal midazolam (one patient) and rectal diazepam (one patient) were also prescribed. The majority of patients (92%) died and almost half (46%) died within a week of parenteral anticonvulsant prescription. Conclusion Levetiracetam via CSCI was the most commonly used parenteral anticonvulsant. Midazolam via CSCI tended to be used for patients with a poorer prognosis (under one week). Regional guidelines need to be reviewed to reflect clinical practice. Given the widespread use of levetiracetam, further research is warranted to guide use in the palliative care setting.