Rescue Medications and Seizure Action Plans in Practice

Key Takeaways

• Quick, effective management of cluster seizures is important to prevent progression to tonic-clonic or grand mal seizures.
• Rescue medications can be used on top of maintenance medications for epilepsy to address breakthrough or cluster seizures.
• Providing patient/caregiver education and a seizure action plan, whether formal or informal, is an essential aspect of epilepsy care.

A person with well-managed epilepsy may experience breakthrough seizure episodes. If these breakthrough episodes are coming on in clusters (or “flurries”), additional management with rescue medication may be warranted. In this case example of a woman with medically refractory epilepsy, rescue medications—in addition to maintenance medications—have helped her live a safer, fuller life.

Patient Profile
This is a 22‑year‑old female with mild intellectual disability and who has had epilepsy for her entire life. She lives with her parents and works a part-time job as a cashier during the day. She takes 3 medications to control her seizures but continues to have breakthrough events despite these maintenance medications. 

Her seizures are of 2 main types: She has generalized tonic‑clonic seizures, as well as episodes in which her head drops and she becomes confused and disoriented. The tonic-clonic seizures tend to occur only at night while she is asleep; the other episodes occur during the day. These daytime episodes—which occur once or twice a month—can last approximately 1 minute, and she recovers relatively quickly. However, at times they tend to occur in clusters, meaning 2 or 3 can occur in a row in the span of a few hours. When that happens, she becomes more confused and disoriented, and she needs to come home if she is at work or outside the home (eg, socializing, shopping). These flurries have become a safety and quality of life issue.

A few times, her breakthrough seizure clusters have led to a tonic‑clonic seizure, which results in an ambulance being called to take her to the hospital. This often results in unnecessary emergency department visits and increased cost.

To control these cluster seizures, she needed something beyond her 3 maintenance medications. 

Medication Management
She tolerates her 3 maintenance medications well. They are controlling her nighttime generalized tonic-clonic seizures quite effectively—she rarely has them now. The daytime episodes have greatly diminished as well, but as discussed, when she has them, they often occur in clusters. To try to mitigate the risk of seizure clusters, we have tried strategies such as adding a fourth medication and increasing the dose of the 3 established medications. However, with those approaches, she starts to have a lot of side effects, necessitating a return to the original 3-medication regimen.

One of the things that has worked to mitigate the risk of these seizure clusters is the use of an intranasal benzodiazepine rescue medication, which she has been taking successfully for the past 3 years. When she was a child, we also used rescue medication, but it was a rectal formulation. Although efficacious, a rectal route of administration is obviously not ideal for her, especially in social or professional scenarios.

With the intranasal formulation, there are fewer concerns for embarrassment, privacy, and administration difficulties. For example, at the beginning of a seizure—or right after one—she is able to self-administer the rescue medication. Sometimes, she can tell when it is going to be a bad day with many seizures, and she can preemptively take the medication after the first head drop seizure. However, after taking the medication, she is usually very tired, so even if she is able to self-administer the medication, it is always good if an observer or caretaker is around.

I prescribe her 4 doses at a time; this way she keeps one in her purse, one with her employer, and a couple of doses at home. Based on our experience managing her epilepsy, I feel that is the right amount for her to have at once. She doesn’t have so many doses that they expire, but she is able to have one in every important location. As soon as she uses one up, she replenishes that with the extra one at home. When she has used up 2 doses, I renew her prescription or she gets a new refill.

Rescue medications are not for daily use, so I have asked her to only use up to 2 doses for a single cluster event or in a 24‑hour period. If she needs more than that, then she has been instructed to call to call me or go to the emergency department, depending on the severity of the seizures.

Education and Action Plan
One of the other important things we have done to help her in her day-to-day life is make sure that her employer and friends are aware of her epilepsy and how to respond to a seizure. In some populations, such as children or those living in a group home, the action plan is written out in a more formal, distributable format. For this woman, we decided that it was sufficient to have a discussion with the employer and provide a short written document with instructions. For example, if she has a typical mild seizure, the employer is educated to allow her to administer her rescue medication—or administer it for her—to minimize a subsequent episode or development of a tonic-clonic seizure. Because of the medication making her tired, they also should allow her to rest before returning to work. If she has a more serious seizure or a cluster, they need to know at what point an ambulance should be called and how to reduce risk of injury. In addition to this, she does wear a medical bracelet so that, in the event of a seizure around strangers, someone is still able to provide appropriate help.

Your Thoughts?
By using rescue therapy on top of maintenance medication, and by providing adequate education to this woman and her family, friends, and employer, she is able to more effectively manage her epilepsy and lead a safer, fuller life. What has your experience been with incorporating rescue therapies into epilepsy care? Answer the polling question and join the conversation in the comments.

For more information on rescue medications and seizure action plans, watch the on-demand webcast “Planning Ahead: Development of a Seizure Action Plan With Rescue Medications.”