Abstract

Phenytoin is commonly used for seizure prophylaxis in patients with traumatic brain injury at Mulago National Referral Hospital in Kampala, Uganda. However, phenytoin therapeutic drug monitoring is not available in this low-resource setting. Anecdotes of breakthrough seizures in patients on phenytoin from healthcare providers at this institution prompted this quality improvement study. This study aimed to characterize prescribing practices for phenytoin and other antiepileptic drugs and then identify improvement strategies for seizure prophylaxis in patients with traumatic brain injury. A retrospective medical chart review was conducted to retrieve information, including dosage and timing of all antiepileptic drugs prescribed in relation to admission and surgery, duration of therapy, doses documented as administered to the patient, adverse reactions, and laboratory test results. Of 28 patient charts reviewed, 12 different regimens of phenytoin were prescribed, 250 mg IV twice daily was the most common, and only 28.6% of patients had loading doses. The duration of antiepileptic drug use was >7 days in 89% of patients. Lamotrigine was also prescribed in 57.1% of patients, and the starting doses were higher than recommended in drug dosing references. Administration of antiepileptic drugs was charted in <50% of patients. This study revealed opportunities to improve seizure prophylaxis, including standardization of phenytoin prescribing with loading doses, reducing the length of therapy to no more than 7 days, discontinuing the use of lamotrigine, and recognizing the benefits of a clinical pharmacist as part of the healthcare team to assist with pharmacovigilance.

Key words: Antiepileptics, developing countries, phenytoin, seizure prophylaxis, traumatic brain injury, Uganda.