A 28-year-old woman is brought to the emergency department by her sister after a generalized tonic-clonic seizure. The patient appears confused and is unable to answer questions. Her sister says that the patient has never had a seizure before and does not use alcohol or illicit drugs. The sister is unaware of any medical or psychiatric history but reports that sometimes the patient feels anxious and sad and has trouble sleeping. For the past 6 months the patient has been taking medication, prescribed by her primary care doctor, to help with these issues. The sister says that the patient had not taken any of the medication in 2 days, as they were on their way to a concert in another state. There is no family history of seizure disorder. Which of the following medications was this patient most likely taking?

Question

A 28-year-old woman is brought to the emergency department by her sister after a generalized tonic-clonic seizure.  The patient appears confused and is unable to answer questions.  Her sister says that the patient has never had a seizure before and does not use alcohol or illicit drugs.  The sister is unaware of any medical or psychiatric history but reports that sometimes the patient feels anxious and sad and has trouble sleeping.  For the past 6 months the patient has been taking medication, prescribed by her primary care doctor, to help with these issues.  The sister says that the patient had not taken any of the medication in 2 days, as they were on their way to a concert in another state.  There is no family history of seizure disorder.  Which of the following medications was this patient most likely taking?

Quizplus · Accepted Answer

This patient had a first seizure after missing doses of her medication for 2 days. Of the medications listed, alprazolam, a short-acting benzodiazepine, is the most likely to result in seizures following abrupt discontinuation. Symptoms of withdrawal from benzodiazepines with short half-lives can appear as early as 24 hours after cessation and include seizures, tremors, anxiety, perceptual disturbances, and psychosis. Although benzodiazepines are still commonly used in the treatment of insomnia and mixed anxiety and depression, their use can be problematic due to the potential for tolerance, dependence, and abuse. Benzodiazepines with shorter half-lives, such as alprazolam, have a greater risk of more severe withdrawal reactions; this contributes to the drug's reinforcing effects that increase its abuse potential. (Choices B and C) Seizures are potential dose-dependent side effects of the dopamine/norepinephrine reuptake inhibitor bupropion and tricyclic antidepressants, such as clomipramine. These side effects are more likely to be seen in patients susceptible to seizures (eg, epilepsy, electrolyte imbalances), with abrupt dosage increases or doses above the daily maximum. Seizures are not associated with their withdrawal. (Choice D) Lamotrigine is an anticonvulsant used in the treatment of bipolar disorder. Rapid discontinuation could result in seizures in a patient with an underlying seizure disorder. However, this patient does not have a history of epilepsy. (Choice E) Mirtazapine is an alpha-2 receptor antagonist antidepressant that is not associated with seizure following abrupt discontinuation. (Choices F and G) Abrupt discontinuation of paroxetine and venlafaxine has been associated with antidepressant discontinuation syndrome (eg, acute onset of dysphoria, fatigue, dizziness, gastrointestinal distress, flu-like symptoms), but this does not include seizures. Educational objective: Abrupt cessation of alprazolam, a short-acting benzodiazepine, is associated with significant withdrawal symptoms, including a risk for generalized seizures and confusion. References: Benzodiazepine withdrawal seizures and management. (http://www.ncbi.nlm.nih.gov/pubmed/21815323)

A 28-Year-Old Woman Is Brought to the Emergency Department by Her