During surgery, or another invasive procedure like an MRI, a patient may need to be put on medications that they do not normally take. Some medications can interact and cause regular medications to work differently. This section will discuss many commonly utilized medications in the context of surgery and other procedures, as well as medication that is commonly used in Dravet syndrome, focusing on potential risks of interactions that may be of concern. This guide should not be used in place of conversations with health care professionals managing the patient with Dravet syndrome’s care. Caregivers should use this guide to help inform conversations as part of the health care team, working with medical professionals to determine the best medications to use given the individual patient’s medical history and the intended outcome from each procedure.
Individuals with Dravet syndrome are often already taking several daily medications to help control seizures and address other comorbidities. It is very important to give the surgical team a list of the current medications your child or loved one is taking. You should discuss your current medication regimen with the surgical team. Upon admission, give the surgical team a list of current medications.
Important information for your medication list includes:
- Name of medication (including brand or generic formulation)
- Dose (mg instead of mL will help to prevent confusion)
- Frequency (how many times per day is the medication taken)
- Route of administration (by mouth, G-tube, J-tube, etc)
- Specific times administered (including time of last dose)
- Any special methods or notes for administering
Some medications may increase the risk of seizures or make current seizure medications act differently. For this reason, it is particularly important to have a Seizure Action Plan developed with the patient’s neurologist with explicit instructions for rescue interventions within a medical setting (including which medications should be avoided). Carry a copy with the patient at all times and be sure to share a copy of the plan with the surgical or medical team. For more information on Seizure Action Plans, you can visit the Seizure Action Plan Coalition’s website.
Medications used in Imaging Procedures:
It is common for patients with Dravet syndrome and other forms of epilepsy to have imaging procedures, like MRIs, to allow doctors to better understand the structure of their brain and how they may be related to their epilepsy and symptoms. Some medications used for imaging procedures (like MRIs) help to make parts of the body easier to see in the resulting images; these types of medications are called “contrast agents.” Patients may also need a medication to help decrease agitation while they are being required to lie still for a procedure for an extended length of time. Many commonly used contrast agents, and more rarely medications to decrease agitation, have the potential to lower the seizure threshold, meaning a seizure could be more likely to occur when this medication is used in any individual. Discuss any concerns you have with the medical team performing the procedure; the patient’s medical team will choose the most appropriate medications based on their full individual medical history and the type of procedure being performed. It is very important to have a Seizure Action Plan developed with the patient’s neurologist with explicit instructions for rescue interventions within a medical setting (including which medications should be avoided). Carry a copy with the patient at all times and be sure to share a copy of the plan with the surgical or medical team. A list of common medications used in imaging procedures, their purpose, and an indication of whether that medication may lower the seizure threshold are all included in the PDF available for download below.
Anti-Seizure and other Common Medications and Potential Interactions with Contrast Agents:
As we discussed above, some contrast agents may lower the seizure threshold for any individual. In addition, some contrast agents may interact with medications that are commonly used in the treatment of Dravet syndrome. The patient’s health care team will make the decision with you based on the patient’s full medical history and the procedure being done. If your physician determines the best contrast agent is one that does have an increased risk of seizures, they may recommend a supplementary dose of an anti-seizure medication prior to the procedure. Again, be sure to have a Seizure Action Plan with explicit instructions for a seizure emergency within a medical setting. A list of common anti-seizure medications, as well as other common medications, and their potential interaction with contrast agents is included in the PDF available for download below.
Considerations for Commonly Used Medications in Surgical and Other Procedures:
During surgery or complex procedures, it is very important that patients are comfortable. Many medications are needed to achieve this level of comfort. Below is a brief overview of the types of medications and some points of concern. The PDF included at the end of this section includes tables to list the specific medications and provides additional details of interactions or topics to consider.
(1) pain medications: IV pain medications are often given to keep patients comfortable during the surgery. Intravenous lidocaine should be avoided in Dravet syndrome, as it is a sodium channel blocker that could worsen seizures; however, subcutaneous or topical lidocaine (used just below or on the skin) should not be an issue and these routes of administration are still reasonable to use. The common anti-seizure medication for Dravet syndrome, stiripentol (Diacomit), can increase the amount of the pain medication sufentanil in the body.
(2) sedation medications: Sedation medications are used during surgery or procedures to ensure patients remain asleep. Some sedation medications may lower the seizure threshold or others may interact with specific anti-seizure medications and change the way the body processes those medications.
(3) paralytics: In order to have a successful procedure, patients have to remain still. Paralytics are used to keep patients still. Some paralytics may interact with the anti-seizure medication carbamazepine, which is not generally used in Dravet syndrome as it can worsen seizures through its action on sodium channels.
(4) anti-seizure medications: During surgery, IV anti-seizure medications may be needed to prevent seizing during longer procedures. Fosphenytoin is generally avoided for use in Dravet syndrome because it may worsen seizures.
(5) reversal agents: Everyone reacts differently to different medications. To prevent patients from becoming too sleepy or too still, the surgery team will have reversal agents on hand. A few of these medications, like flumazenil, may need to be carefully considered before use in an individual with epilepsy as it could lower the efficacy of some anti-seizure medications or lower the seizure threshold.
(6) antibiotics: Antibiotics are an extremely important way of preventing infections from complicated surgeries. They can be given before and after the surgery, either via IV or injected directly to the site of infection risk. There are no pertinent drug interactions with antibiotics and anti-seizure medications.
(7) stabilizers: A patient’s body can react in many different ways to a surgical procedure. The surgery team will have access to several stabilizers to keep vitals all in equilibrium. Some stabilizers may interact with specific anti-seizure medications.
(8) anti-inflammatory agents: During and after the procedure, the help of some steroids may be needed to decrease inflammation. They will typically start with a higher dose and slowly decrease down over time. These medications may be rough on the stomach, so they are typically given with some tummy protection (anti-acids). There are no pertinent drug interactions with steroids, anti-acids and anti-seizure medications.