As a veterinarian, I am constantly presented with problems that do not have clear solutions. My training has taught me that I have to evaluate a problem from many perspectives. I have to draw conclusions and make decisions without the benefit of the patient telling me how they feel or what the real problem is. Many times, I have to be inventive which means I have to improvise, and use my knowledge and resourcefulness to find a reasonable solution, and to create a successful treatment plan. Thinking outside the box as a veterinarian has been a skill I have used both in my practice and as a parent of a son with intractable epilepsy. Having exhausted so many avenues of treatment options for my son Brian, I realized I could apply my skills and training as a veterinarian towards finding and creating an alternative treatment for my son’s seizure problem. As such, I recently collaborated with Pharmacy Innovations, a compounding pharmacy in Jamestown New York, to formulate a rapid dissolving form of lorazepam.

Brian’s Battle with Epilepsy

My son has had epilepsy since the age of 8. It started on the night before he started the third grade. It was a violent grand mal tonic clonic seizure that lasted 1-2 minutes, though it seemed like an eternity. That was the start of the unending nightmare that my son still endures today. On March 5th of this year Brian will turn 21. This is a time when most people are well into their early adult life, but not him. He currently resides in a rehab facility for people with brain injuries. We are trying to teach him to deal with life, and life with epilepsy. We have never found the cause of that first seizure. Having him evaluated at two major epilepsy centers, and a multitude of other doctors, countless MRIs, CT scans, PET scans, EEGs, Video EEGs etc, etc., no etiology for his seizures has ever been discovered. At one time in this horrible journey he was having 5-6 major grand mal tonic clonic seizures a night. Functioning on a daily basis doing the most basic of things became unbelievably difficult for him, not to mention going to school and trying to be a normal kid. To date, his doctors have tried at least twelve different medications and combinations of the twelve. He has endured two major brain surgeries, which resected different areas of the right side of his brain, and he has a vagal nerve stimulator (VNS) implanted in his chest. I have come to realize that until medical research finds new methods of seizure diagnosis and control, my son will continue to endure not only seizures but all of the other issues that go along with epilepsy.

People like Brian have to deal with the fear of having seizures while in public and the constant stigma that follows. And yet I know Brian is not alone and that his struggles and hurdles are not his to bear alone. Unfortunately, in our society people with epilepsy are discriminated against by those who do not understand the nature of epilepsy. Many patients with seizures take medication that slows their thinking and dulls their response time and often times are labeled “stupid.” In addition, obtaining and maintaining employment is an issue as employers are worried about liability issues, missed work, low productivity etc. What are people with epilepsy suppose to do? These people did not ask to have epilepsy and most would give anything to be seizure-free. Many have attempted to live a “normal” life, but society puts many roadblocks in their way. The absolute worst thing for Brian has been not being able to get his driver’s license. He has not been allowed to engage in one of the most important rites of passage into adult life and therefore will never experience the independence that all teenagers feel the day they earn their driving privileges. Even during all the years of testing, medication trials and countless seizures Brian never complained. He always smiled and reassured me that he was OK. However when the reality that he would never be able to drive really hit home he was devastated. In his mind, this was the most dreadful thing that could happen. There are no words that can console my son about driving. I personally believe that if he could drive, he would be able to deal with all of the other issues.

An Alternative Treatment for Prolonged Seizures

Like many children with intractable epilepsy, my son suffers two different seizure types. There are the tonic clonic form and cluster seizures that last anywhere from several minutes to several hours. When these occur we have been instructed by his doctors to give him a tablet(s) of lorazepam orally. However, since the absorption of this form of drug is slow, attaining an adequate blood level to interrupt the seizure takes longer than other alternative routes of delivery. Besides giving our son a tablet form of lorazepam we have two choices:

1. We can administer Diastat (Valium) rectally, which is effective but a humiliating experience for my son.
2. We can take him to a hospital where he receives the medication intravenously (IV).

The IV method delivers a therapeutic dose of medication rapidly, and the cluster seizures stop immediately.

However, repeated trips to the emergency room present many problems such as having to go through his medical history with every new doctor as well as proving to the doctor that I know what I am talking about when I tell them, “Just give him 2 mg of lorazepam IV and we will be on our way”. Frustrated with the treatment options available to us I began investigating a method of delivering lorazepam in a manner that would:

• Give us a rapid therapeutic drug level
• Could be administered at home
• Be more acceptable to the patient

What I found during my research was that sublingual (under the tongue) administration is a fast and efficient form of delivery. For example, two medications that I know of, one in human medicine, Maxalt for migraine headaches and one in veterinary medicine, Zubrin, a non-steroidal anti-inflammatory medication, are given to the patient in the form of a rapid dissolve tablet. The tablet is placed between the gum and the cheek, or under the tongue. This tablet is rapidly dissolved and the medication is absorbed through the mucous membranes of the mouth. This delivers a blood level of drug much faster than a swallowed tablet, however not as good as an IV injection.

I consulted with a compounding pharmacy that I use in my veterinary practice, and they agreed that in theory my thoughts made sense. However they also told me that the technology and equipment to make rapid dissolve tablets was a very special process. With their help we located a compounding pharmacy, Pharmacy Innovations in Jamestown New York,that had the technology and expertise, and was willing to work with me. After consulting with my son’s doctor, a dosage was calculated and lorazepam in rapid dissolve form was formulated.

Fortunately, to date, we have only had the opportunity to try this medication on two occasions. The first was with the onset of a cluster seizure, which abated very quickly after he took the tablet. The second time, my son felt “funny”, which may have been an aura, but we are not sure, however he took a rapid dissolve tablet and a seizure never did materialize.

It is very premature to make comments on the efficacy of this rapid dissolve medication; however it may offer some hope to patients in the future. Much more thought and work must be invested to determine if this is indeed a viable treatment method. I am currently investigating many aspects of rapid dissolve tablet medication and hopefully I will stimulate thought and interest on a larger scale.

I would encourage involvement and dialogue from anyone that has an interest in this topic. I can be reached via e-mail: WerKenDoc@aol.com

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Kenneth Werner DVM