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Phenytoin

Dilantin 

Dilantin, the brand name for phenytoin, is an established anticonvulsant used to control and prevent seizures, including those associated with brain surgery. It works by stabilizing electrical activity in the brain to avoid seizure episodes. Available in various forms such as capsules, tablets, oral suspension, and injectable solution, Dilantin must be taken consistently to maintain effective blood levels. Common side effects include dizziness and coordination issues, while serious reactions may involve liver damage and severe allergic responses. Regular monitoring and blood tests are crucial for managing its use safely. Dilantin can interact with other medications and alcohol, impacting its effectiveness and safety. It should be stored properly and kept out of reach of children. Always consult a healthcare provider for guidance tailored to individual health needs.

Product Overview

Dilantin, known generically as phenytoin, is an anticonvulsant medication primarily used to prevent and control seizures, including tonic-clonic (grand mal) seizures and psychomotor seizures. It is also utilized during and after brain surgery to manage seizure activity. FDA-approved, Dilantin operates by slowing down impulses in the brain that cause seizures. By stabilizing neuronal membranes, Dilantin reduces excessive electrical brain activity, thereby preventing seizure episodes. Dilantin is available in various forms including immediate-release capsules (30 mg and 100 mg), extended-release capsules (100 mg, 200 mg, 300 mg), chewable tablets (50 mg), oral suspension (125 mg per 5 mL), and an injectable solution (50 mg/mL). 

It should be taken as prescribed by a healthcare provider, generally three times daily, for seizure control, with or without food. Consistency in the timing of doses is crucial for maintaining stable blood levels of the medication. Extended-release capsules should be swallowed whole, not crushed or chewed. Common side effects of Dilantin include dizziness, slurred speech, and coordination problems. Serious side effects may include severe allergic reactions, liver damage, and potentially life-threatening skin reactions. It’s crucial to monitor for signs of these reactions and consult a healthcare provider immediately if they occur. Regular blood tests may be required to monitor Dilantin levels and prevent toxicity. 

Missing a dose can lead to increased seizure activity; if a dose is missed, it should be taken as soon as possible unless it is almost time for the next dose. In case of an overdose, immediate medical attention is necessary. Dilantin should be stored at room temperature, away from light and moisture. It is important to keep this medication out of reach of children and properly dispose of any unused or expired medication. Patients should be aware of potential interactions with other drugs, such as antacids, which can affect how well Dilantin works. Avoiding alcohol and assessing the need for adjustments with other medications or supplements is also essential to ensure safety and efficacy.

Uses of Dilantin

  • Tonic-clonic (grand mal) seizures
  • Psychomotor seizures (originating in the temporal lobe)
  • Seizures occurring during and post-brain surgery

How to Use Dilantin?

Dosage

Dilantin comes in multiple forms and dosage strengths like the following:

  • Immediate-release capsules:
    • 30 mg
    • 100 mg
  • Extended-release capsules:
    • 100 mg
    • 200 mg
    • 300 mg
  • Chewable tablets:
    • 50 mg
  • Oral suspension:
    • 125 mg per 5 mL
  • Injectable solution:
    • 50 mg per mL

Recommended Dosage for Different Patients

Adults:

  • For Seizure Control: The typical initial dose is 100 mg thrice daily. The dosage may be adjusted based on blood levels and individual response, generally within 300 to 600 mg daily.
  • For Status Epilepticus: In emergency situations, a loading dose might be used, followed by maintenance dosing depending on clinical response and phenytoin blood levels.

Elderly:

  • General Use: Start at the lower end of the dosing range due to potential increased sensitivity to the drug. Close monitoring of phenytoin serum levels and patient response is recommended to adjust the dose accordingly.

Children:

  • For Seizure Control: The maintenance dose is usually 5 mg/kg/day in two or three equally divided doses, with a maximum maintenance dose typically not exceeding 300 mg daily. The initial dose is normally 5 mg/kg/day in two to three divided doses for infants.

Patients with Renal or Hepatic Impairment:

  • Adjusted Dosing: Lower or less frequent dosing may be necessary due to altered drug metabolism and excretion. Monitoring of phenytoin blood levels is essential to avoid toxicity.

[Note: Remember, these recommendations may vary from person to person. Discuss it with your doctor, and they’ll customize your dosage accordingly.]

How to Take It?

  • Take Dilantin at the same time each day to maintain an even level of medication in your blood.
  • You can take Dilantin with or without food, but it’s best to be consistent in how you take it relative to meals. If you find it upsets your stomach, try taking it with food.
  • Do not crush, chew, or break the capsules. Swallow them whole. For the extended-release capsules, it’s particularly important to swallow them whole to ensure the medication is released slowly in the body.
  • If prescribed the oral suspension, shake the bottle well before each use to ensure the medication is evenly mixed. Use a medicine dose-measuring device (not a kitchen spoon) to ensure you get the correct dose.
  • Do not drink alcohol while taking Dilantin, as it can increase the risk of side effects and interfere with the effectiveness of the medication.
  • You will likely need regular blood tests to check Dilantin levels and monitor for side effects, especially if you’re starting treatment, changing doses, or have recently stopped taking the medication.
  • Stopping Dilantin suddenly can cause serious problems, including frequent seizures that may not stop (status epilepticus). If you need to stop taking Dilantin, your doctor will lower your dose gradually.

[Note: Your doctor will decide the right amount for you based on your condition, following guidelines and studies on the drug. They’ll adjust it as needed over time.]

How Does Dilantin Work?

Dilantin, the brand name for phenytoin, is an anticonvulsant medication primarily used to manage and prevent seizures. It works by stabilizing the electrical activity in the brain. Phenytoin does this by reducing the ionic fluxes across neuronal membranes necessary for initiating and transmitting electrical impulses. This action helps to prevent the excessive brain activity that leads to seizures. By modulating sodium channels in the neurons, Dilantin slows down the overactive electrical firing in the brain, making it an effective treatment for controlling seizures without sedating the patient.

Important Safety Information

Side Effects

Common side effects of this medication include:

  • Uncontrolled eye movements
  • Impaired or deteriorating coordination
  • Slurred speech
  • Increased sleepiness
  • Confusion

Mild side effects of this medication may include:

  • Nystagmus: Uncontrollable eye movements.
  • Coordination Difficulties: Trouble with tasks requiring coordination, such as walking.
  • Slurred Speech: Difficulty speaking clearly.
  • Drowsiness: Increased feelings of tiredness.
  • Confusion: Reduced clarity of thought or disorientation.
  • Mild Allergic Reaction: This may include rash, itching, or minor swelling.

Serious side effects of this medication and their possible symptoms include:

Heart issues, such as a low heart rate or heart attack, which may manifest as:

  • Dizziness
  • Chest pain or pressure
  • Shortness of breath

Liver complications, such as acute liver failure, with potential signs include:

  • Jaundice (yellowing of the skin or eyes)
  • Elevated liver enzymes
  • Abdominal pain

Severe skin reactions, which might present as:

  • Skin rash
  • Blisters
  • Peeling skin

Blood disorders, such as:

  • Anemia (low red blood cells), potentially causing fatigue
  • Thrombocytopenia (low platelets), which can lead to bruising or bleeding
  • Leukopenia (low white blood cells), increasing the risk of infections and fever

Mental health changes, including:

  • New or worsening depression
  • Unusual mood or behavior changes
  • Thoughts of suicide or engaging in suicidal behavior

[Note: Remember, this list may not cover all possible side effects. Always consult with your healthcare giver for medical advice about side effects.]

Warnings

  • Withdrawal Seizures: Abrupt discontinuation of phenytoin (Dilantin) can lead to severe or prolonged seizures. Consult your healthcare provider before stopping or altering your medication to ensure safe discontinuation or transition to another treatment.
  • Suicidal Thoughts or Behavior: Phenytoin may increase the risk of suicidal thoughts or behavior as early as one week after starting treatment. Monitor for any changes in mood or behavior, especially during initial months or dose adjustments. Immediate help should be sought if suicidal thoughts occur.
  • Severe Allergic Reactions: Phenytoin can cause life-threatening skin reactions like toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS), especially in individuals of Asian descent or those with the HLA-B1502 gene. Symptoms include fever, swollen lymph nodes, and organ damage. Emergency medical attention is needed for symptoms like facial swelling or difficulty breathing.
  • Heart Effects: Phenytoin can cause significant heart-related issues, including a slow heart rate or cardiac arrest, particularly in individuals with existing heart conditions.
  • Serious Liver Damage: Rarely, phenytoin can cause severe liver damage, manifesting as fever, stomach pain, unusual skin rash, or jaundice. Immediate medical consultation is recommended if these symptoms appear.
  • Changes in Blood Cell Counts: Phenytoin may reduce white blood cells, red blood cells, and platelets. Regular blood tests are advised to monitor blood cell levels.
  • Effect on Vitamin D and Bones: Long-term use of phenytoin can decrease vitamin D and calcium levels, potentially leading to osteoporosis and increased risk of fractures. Monitoring for bone health is advised for at-risk patients.
  • Phenytoin Levels Too High: High blood levels of phenytoin can cause neurological issues such as dizziness, slurred speech, confusion, and potentially irreversible brain damage. Monitoring of phenytoin levels is crucial, especially in patients with liver or kidney issues, low albumin levels, or those who metabolize the drug slowly.
  • Harm to Unborn Baby: Phenytoin poses risks to the unborn baby, including birth defects and developmental issues. Pregnant women or those planning to become pregnant should discuss the use of phenytoin with their healthcare provider.
  • High Blood Sugar Levels: Phenytoin may increase blood sugar levels. People with diabetes should monitor their glucose levels closely while using phenytoin.

Boxed Warning

Dilantin carries a boxed warning, the strongest warning the FDA requires, indicating significant risks of serious or life-threatening adverse effects. The main points of the boxed warning for Dilantin include:

  • Cardiovascular Risk with Rapid Infusion: The intravenous administration of phenytoin can cause severe cardiovascular reactions, including arrhythmias and hypotension, especially when given at a high rate. It is critical to administer the IV form slowly and monitor the patient’s blood pressure and ECG during administration.
  • Dermatological Reactions: Phenytoin has been associated with severe and life-threatening dermatologic reactions, such as Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). These reactions are most often observed within the first few months of treatment. Patients should be informed of the signs of severe skin reactions, and the drug should be discontinued at the first sign of a rash or any other indication of hypersensitivity.
  • Hepatic Injury: Phenytoin can cause severe liver damage, including acute hepatic failure. Liver function tests should be performed before therapy and at periodic intervals during treatment, especially during the first six months, which is when drug-induced hepatotoxicity most commonly occurs.

Precautions

  • Allergies: Inform your doctor or pharmacist if you are allergic to phenytoin or other anti-seizure medications (e.g., carbamazepine, ethosuximide). This product may also contain inactive ingredients that can cause allergic reactions.
  • Medical History: Disclose your medical history to your healthcare provider, particularly if you have a history of alcohol use, blood disorders (like porphyria), diabetes, liver disease (including previous liver issues caused by phenytoin), lupus, or deficiencies in folate or vitamin B-12.
  • Dizziness and Drowsiness: Phenytoin may cause dizziness or drowsiness. Avoid alcohol and marijuana as they can exacerbate these effects. Do not engage in activities that require alertness, such as driving or operating machinery, until you can do so safely.
  • Surgery: Before undergoing any surgery, inform your doctor or dentist about all the products you use, including all medications and supplements.
  • Diabetes Management: Monitor your blood sugar levels regularly, as phenytoin may affect blood sugar control. Discuss the results with your doctor, who may adjust your diabetes medications or diet.
  • Bone Health: Discuss with your doctor the potential need for vitamin D supplements to prevent osteomalacia, especially during long-term use of phenytoin.
  • Pregnancy: Use phenytoin during pregnancy only when necessary due to potential risks to the unborn baby. Untreated seizures can also pose risks; do not stop taking phenytoin unless advised by your doctor. Discuss contraceptive methods with your doctor, as phenytoin may decrease the effectiveness of hormonal birth control.
  • Breastfeeding: Phenytoin is excreted in breast milk. Consult your doctor before breastfeeding to understand any potential risks to the infant.

Other Important Precautions

Before starting Dilantin, reviewing your medical history with your healthcare provider is crucial. This medication may be unsuitable if you have specific health conditions or factors. Ensure you discuss the following with your doctor if they apply to you:

  • Existing or previous mental health issues such as depression, mood disorders, or suicidal thoughts.
  • Kidney or liver dysfunction.
  • A history of porphyria, a rare blood disorder.
  • High blood sugar levels (hyperglycemia).
  • Any allergic reactions to Dilantin or similar medications in the past.
  • If you are pregnant or planning to become pregnant.
  • If you are currently breastfeeding.
  • Your alcohol intake.

Contraindications

Dilantin should not be used by patients with:

  • A known allergy to phenytoin, its inactive ingredients, or other hydantoins could result in severe reactions such as angioedema.
  • A previous experience of acute liver toxicity directly linked to phenytoin use.
  • Concurrent use with delavirdine can decrease virologic response and potentially resistance to delavirdine or other non-nucleoside reverse transcriptase inhibitors.

Missed Dose

If you forget to take a dose of Dilantin, take it as soon as you realize it. If it’s close to the time for your next dose, skip the missed dose and continue with your regular dosing schedule. Do not take a double dose to make up for the missed one. If you’re unsure about what to do, consult your doctor or pharmacist for guidance.

[Note: If you have missed a medication dose and are unsure when to take the next one, immediately consult your doctor or pharmacist.]

Overdose 

An overdose of Dilantin is a serious medical emergency that necessitates immediate medical intervention. Symptoms can range from severe drowsiness, uncontrollable eye movements, and tremors to more critical conditions such as loss of balance or coordination, slurred speech, nausea, and vomiting. Other severe signs include a rapid or irregular heartbeat, fainting, difficulty breathing, and even coma.

[Note: If you consumed more than the recommended dose, get medical help immediately or call the Poison Help line at 1-800-222-1222.]

Storage

  • DILANTIN Capsules:
      • Store at room temperature between 68°F to 77°F (20°C to 25°C) in tight, light-resistant containers.
      • Protect from moisture.
      • Keep out of the reach of children.
  • DILANTIN-125 Suspension:
      • Store at room temperature between 68°F to 77°F (20°C to 25°C).
      • Protect from light.
      • Do not freeze.
  • DILANTIN INFLATABLES:
    • Store at room temperature between 59°F to 86°F (15°C to 30°C).

[Note: Discuss with your healthcare professional the proper disposal of unused medicine and any questions you may have regarding its storage.]

Dilantin Interactions

  • Antacids and Nutritional Supplements: Antacids, calcium supplements, and other nutritional supplements can decrease the absorption of phenytoin. It is recommended to take phenytoin at least 2 hours before or after these products.
  • Other Antiseizure Drugs: Some anti-seizure medications, such as valproic acid, can affect the levels of phenytoin in the blood, either increasing or decreasing its concentration, which may necessitate dosage adjustments.
  • Antifungal Medications: Drugs like fluconazole, ketoconazole, and itraconazole can increase phenytoin levels, potentially leading to toxicity.
  • Antidepressants and Antipsychotics: Some of these medications can interfere with the metabolism of phenytoin, leading to increased levels and potential side effects.
  • Warfarin: Phenytoin can increase warfarin’s metabolism, reducing its effectiveness and requiring close monitoring of blood coagulation parameters.
  • Corticosteroids: Phenytoin may decrease the blood levels of corticosteroids, potentially reducing their effectiveness.
  • Oral Contraceptives: Phenytoin can decrease the effectiveness of hormonal birth control, leading to an increased risk of unintended pregnancy.
  • Cimetidine, Omeprazole, and Other Stomach Acid Reducers: These can increase phenytoin levels, potentially leading to toxicity.
  • Alcohol: Chronic alcohol intake can alter phenytoin metabolism, whereas acute alcohol use may increase phenytoin levels, leading to toxicity.
  • Antibiotics: Certain antibiotics, such as doxycycline, can reduce their effectiveness by phenytoin.

[Note: This isn’t a complete list, and there could be other drugs that interact with Dilantin. Make sure to tell your doctor about any prescription, over-the-counter medicines, and herbal products you’re taking.]

Dilantin Alternatives

  • Keppra (levetiracetam)
  • Briviact (brivaracetam)
  • Carbatrol, Tegretol, and others (carbamazepine)
  • Epidiolex (cannabidiol)
  • Depakote and Depakote ER (divalproex)
  • Neurontin (gabapentin)
  • Lamictal (lamotrigine)
  • Trileptal (oxcarbazepine)
  • Fycompa (perampanel)
  • Phenobarbital (phenobarbital)
  • Lyrica (pregabalin)
  • Topamax (topiramate)
  • Valproic acid (valproic acid)

[Note: Your doctor will choose what’s best for you. Don’t use any of these alternative medications without consulting your healthcare provider. Taking them by yourself may cause serious side effects.] 

Frequently Asked Questions

Can Dilantin be used to treat other types of seizures?

While Dilantin is not officially approved for seizure types beyond its usual indications, it has been researched for use in various other seizures, including refractory seizures, simple partial seizures, and secondary generalized seizures. Your neurologist can determine whether phenytoin is suitable for treating your specific seizure condition.

Is it safe for pregnant women to take Dilantin?

Phenytoin (Dilantin) can significantly increase the risk of birth defects if taken during pregnancy, particularly in the first trimester. There is a 5 to 10% chance of the unborn baby developing Fetal Hydantoin Syndrome, which affects growth and brain development if the mother takes phenytoin during early pregnancy. If you are pregnant or planning to become pregnant, consult with your healthcare provider about your options. Alternative anti-seizure medications may be more suitable and safer for your unborn child. Additionally, pregnant women taking phenytoin are encouraged to enroll in the North American Antiepileptic Drug (NAAED) Pregnancy Registry to contribute to research on the safety of antiepileptic drugs during pregnancy.

Is it safe to drink alcohol while taking Dilantin?

It is advisable not to consume alcohol while taking phenytoin (Dilantin) without discussing it with your healthcare provider first. Alcohol can significantly alter the levels of phenytoin in your body, potentially decreasing its effectiveness and increasing the risk of seizures or causing the levels to become too high, which can lead to severe side effects.

How long does it take for Dilantin to start working?

It takes about 7 to 10 days for the levels of phenytoin in your body to stabilize (reach a “steady state”) on a normal starting dose. Then, your provider will gradually increase the dose to an appropriate amount. It can take up to 4 weeks before you start to feel the full benefit of this drug. Please be aware that you may still have seizures during this time, but they should happen less and less frequently. If you are in a hospital or clinic setting, your provider may “load” you with a large dose of phenytoin (Dilantin) to get your levels up faster.

Can Dilantin be used for pain management?

No, Dilantin, the brand name for phenytoin, is specifically prescribed to treat and prevent certain types of seizures. Unlike some other seizure medications like gabapentin (Neurontin), which is also used for nerve pain, Dilantin is not approved for pain treatment. Additionally, it should not be confused with Dilaudid, a different medication used for severe pain management.

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