ECT in a Patient with Epilepsy on Multiple Anticonvulsant Medications: Case Report

 Out on PubMed, from clinicians in Montana, is this case report:

Successful bilateral electroconvulsive therapy in a patient with a seizure disorder taking levetiracetam, lorazepam, and zonisamide: A case report.

McGrane IR, Tenison RE, Bimler DM, Munjal RC, Molinaro JR.Ment Health Clin. 2021 Jan 8;11(1):23-26. doi: 10.9740/mhc.2021.01.023. eCollection 2021 Jan.PMID: 33505822

The abstract is copied below:

Electroconvulsive therapy (ECT) may be considered for treatment of severe, treatment-resistant, and emergent depression associated with MDD or bipolar disorder. Patients with epilepsy usually take medications that raise the seizure threshold, which poses challenges during ECT. We report a 66-year-old male with epilepsy taking levetiracetam extended-release (XR), lorazepam, and zonisamide requiring ECT for severe MDD. After literature review, the XR form of levetiracetam was changed to higher doses of the immediate-release (IR) formulation, and zonisamide was discontinued 2 days prior to ECT in the hospital and was resumed when the patient underwent outpatient continuation ECT. The patient was treated to remission after receiving 8 acute bilateral ECT treatments before being transitioned to continuation ECT. We provide a brief review of medication management of antiepileptic drugs and other medications that increase the seizure threshold during ECT. To our knowledge, this is the first reported case describing the management of levetiracetam, lorazepam, and zonisamide concomitantly during ECT. Our case suggests that utilizing the IR formulation of levetiracetam, administering the evening dose early the day prior to the procedure, and temporarily discontinuing zonisamide prior to bilateral ECT is effective for the treatment of severe MDD while maintaining seizure prophylaxis.

Keywords: anticonvulsant; benzodiazepine; electroconvulsive therapy; epilepsy; levetiracetam; major depressive disorder; seizure disorder; zonisamide.

The pdf is here.

From the text:

Conclusion 

Management of AEDs and BZDs during ECT poses challenges, especially in patients with seizure disorders. Valproate, carbamazepine, and lamotrigine have been successfully continued during ECT in patients without epilepsy,6-8 and a large case series supports AED continuation in most patients with epilepsy receiving ECT.4 BZDs do not usually impact ECT effectiveness when the dose is held the morning prior to bilateral ECT procedures.3,15 Our case suggests that utilizing the IR formulation of levetiracetam, administering the evening dose early the day prior to the procedure, and temporarily discontinuing zonisamide dosing prior to bilateral ECT is effective for the treatment of severe MDD while maintaining seizure prophylaxis.

This case report, written by a pharmacy school faculty member, a resident and a student, along with psychiatry attendings, gives details of the successful management of seizure-interfering medications during a course of ECT. 

The patient had either severe psychomotor retardation or catatonic features and showed the typical quick, dramatic improvement early in the ECT course.

The clinicians did not need to use flumazenil.

The fact that three different electrode placements were used (BT at #4, RUL at #9, the rest BL) suggests inconsistency in clinical decision making.

Finally, the authors did not comment on the anticonvulsant property of ECT, most relevant for a patient with epilepsy.

This case report is worth a full read, to get re-acquainted with the specifics of the anti epileptic medications used (~10 minutes).