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Sudden discontinuation of anticonvulsants in The Rash (TM)

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I know there has been concern on this board about getting The Rash (aka Stevens-Johnson syndrome) from anticonvulsants, mostly Lamictal (lamotrigine).

I also know that a probably bigger concern is that the doc will suddenly discontinue your anticonvulsant, potentially causing a rebound seizure.

I've yet to find a clinical article that emphasizes the importance of preventing rebound seizures with Stevens-Johnson patients. Given how docs are probably paranoid that other similar anticonvulsants will also give the patients The Rash, maybe they should look at using benzos when they expect the effect of the former AC to wear off. Of course, I'm not a doctor.

Also, I read another "reviewed and respected" clinical article that made absolutely no mention of the potential of rebound epilepsy and just told docs to stop the offending AED/AC cold turkey! The author didn't even suggest a benzo for immediate seizure control, or even mention in his follow-up suggestions that the patient would have to try another AC!!!!!


So I had to write this particular author (more specifically, the main editor of the site's relevant section) with my uh, concerns.

Perhaps SJS does magically make you resistant to rebound seizures upon quitting the AC cold turkey. As my aunt would say, "clinician's intuition is more important than the opinion of one patient or non-clinician researcher". Though I'm not sure how that'd work in this case.

Anyways, below is my rant, although I have a good feeling that I will (and probably deserve to) get flamed for it...

Dr. K**--

It has come to my attention that there exist articles on your site [site] regarding the proper management of Stevens-Johnson syndrome (toxic epidermic necrolysis). In topic #*** (the relevant article by Dr. D. R**) Dr. R** advocates immediate withdrawal of the offending anticonvulsant (where applicable). However, no suggestion is made as to subsequent seizure management, and Dr. R** did not emphasize (or even mention, from my own perusal of the article) the universally-known consequences of suddenly discontinuing antiepileptics.

"Rebound" seizures are a very well-known phenomenon upon discontinuation of these drugs; sudden discontinuation especially, without any sort of replacement, is very likely to precipitate such an event. Not only can these seizures cause morbidity (and even mortality) in patients, they can also expose physicians to liability issues and subsequent malpractice lawsuits.

If the return of SJS/TEN is deemed highly likely upon use of another modern AED, might I suggest that Dr. R** consider, at his discretion, advocation of the use of first-generation anticonvulsants, such as the benzodiazepines. In theory, such intervention must be initiated as soon as the offending drug's therapeutic effect fades away.

Regrettably, very few, if any, publications have been made regarding sudden discontinuation of AEDs in the setting of SJS/TEN, despite the well-known fact that sudden discontinuation of AEDs in other settings may precipiate an epileptic event. I encourage Dr. R** to reconsider his guidelines for treatment of AED-induced SJS/TEN in a way that will decrease patient morbidity/mortality as well as physician liability.

However, I am not a clinician, only a neuroscience researcher, so all advice here cannot be taken as formal and the final decision regarding the advice is solely the responsibility of Dr. R** and the [site] team. Once again, thank you for listening to my concerns.

I'm going to get my asbestos suit on, meanwhile.

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Anyways, below is my rant, although I have a good feeling that I will (and probably deserve to) get flamed for it...

not from me.. I think it needed to be said, AND you said it clearly and succinctly. I'll be interested to hear what kind of reply you get from the doc in question.

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Well, my angle on this is that almost every doc around would rather accept possible seizures than risk SJS.

True SJS is a rapidly developing, devastating and potentially fatal illness with no predictable outcome and no reliable treatment. Wait even a day too long and you have a skin sloughing away and a dead patient.

On the other hand, except for hard case epileptics a doc is going to be able to control seizures immediately and have plenty of time to workout alternate meds.

It's the lesser of two risks.


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On the other hand, except for hard case epileptics a doc is going to be able to control seizures immediately and have plenty of time to workout alternate meds.

I suppose that was the more important thing with respect to these patients... benzodiazepines are not well-known for causing SJS, so yes, as you say, the doc really has little excuse to not aggressively control potential rebound seizures. Valium via IV seems to be the standard, but your ER may vary.

Maybe it's just implicit in the article that benzos or similar should be given to SJS patients who have to quit an AC cold turkey. But it's such a main point, despite how obvious it is, that it should be stated explicitly repeatedly (just my opinion).

SJS is rare enough that I can easily see a burdened ER team forgetting to give an SJS patient (formerly) on an AC something else to control rebound seizures. Especially if "authoritative" medical professional educational articles don't even mention it.

Meanwhile, I'll go see if I can find some published articles on how to treat an SJS patient after stopping the original AC cold turkey. There has to be SOMETHING out there about this. Either that, or there'd be articles regarding physician liability in NOT giving the patient another antiepileptic.

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Heya herrfous,

As usual, only experience to draw on, take with a grain of whatever.

A one-off seizure, observed in emerg, beats the hell out of SJS/TEN.

A one-off seizure is controllable even if it's not prevented. SJS/TEN is unpredictable and can kill.

Most likely in emerg a potential seizure patient (I'm thinking of DTs really) would get Valium or maybe phenobarb.

Also, SJS/TEN would have (if you're lucky enough to be at a teaching centre) burn unit involved before any seizure could happen.

Put it on your Medicalert tag and wallet card.

I'd take a one-off seizure over SJS/TEN any day of the week, personally.



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I was waiting for your input on the subject, glad you're back!

You have a good point in that clinicians will notice the seizure and treat it with a quick-acting AC, likely a benzo. [EDIT: Unless I'm the patient, in which case they'll take one look at my chart, see 'bipolar', and label my seizure as psychogenic.]

It's more the protocol though, I think it does need to be recognized from a physiological standpoint the importance of being vigilant for seizures following new-generation AC discontinuance.

Also, I'm not sure what the doctors think, but some may go on and give the patient some benzo prophylaxis if they realize in advance the danger of suddenly discontinuing an AC. Their mileage will vary, of course.

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