Anti-Seizure Medicines: The Dispensing Safety Checklist

📋 First Dispense Essentials

Mandatory items to issue

• Valproate only: dispense in the manufacturer's original full pack (legal requirement since October 2023). Do not re-pack into plain dispensing containers. Round up or down to supply complete packs only.
• Valproate only: confirm the patient card and Patient Information Leaflet are in the pack. If the card is missing, source a replacement from the MHRA or the manufacturer before dispensing.
• Check the prescription states a specific brand or manufacturer for Category 1 drugs (phenytoin, carbamazepine, phenobarbital, primidone). If it does not, use your usual dispensing practice but record what was supplied.

Baseline clinical checks

• Confirm the indication is epilepsy. MHRA brand-switching rules apply only for epilepsy, not for other uses of the same drug (for example, carbamazepine for pain or valproate for mood).
• Valproate in women and girls of childbearing potential: confirm the PPP is in place. Since January 2024, valproate must not be initiated unless a specialist has confirmed PPP conditions are met and the annual risk acknowledgement form is signed by both patient and prescriber. Since September 2024, men taking valproate and their partners are also advised to use effective contraception.
• Carbamazepine new starts: check whether the patient is of Han Chinese or Thai origin. These patients should be screened for the HLA-B*1502 allele before starting, due to a significantly increased risk of Stevens-Johnson syndrome.

Key risks and lifestyle traps

• <strong>Category 1</strong> (always maintain brand): phenytoin, carbamazepine, phenobarbital, primidone. <strong>Category 2</strong> (maintain where possible): valproate, lamotrigine, topiramate, oxcarbazepine, clobazam, clonazepam, zonisamide, perampanel. <strong>Category 3</strong> (generic usually acceptable): levetiracetam, lacosamide, gabapentin, pregabalin, ethosuximide.
• Enzyme-inducing medicines (carbamazepine, phenytoin, phenobarbital) reduce the effectiveness of hormonal contraceptives and interact with many other medicines. Check for new co-prescriptions at every dispense.
• Valproate increases lamotrigine concentrations significantly, raising the risk of serious skin reactions and toxicity. Any dose change to either drug requires careful monitoring.

First dispense script

🔄 Repeat Dispense Screen

Mandatory documentation

• Record the brand name and manufacturer dispensed on every occasion. If a different brand was supplied due to shortage, document the reason, the prescriber contacted, and the outcome.
• For valproate: record whether the PPP annual risk acknowledgement is current. Flag if it is overdue.

Ongoing clinical checks

• Confirm the brand and manufacturer match what was dispensed previously. Any change for Category 1 or 2 drugs requires prescriber agreement first.
• Drug shortage: before substituting a brand, check the NHS Specialist Pharmacy Service (SPS) Medicines Supply Tool at sps.nhs.uk for current information and alternative supplier details. Contact the prescriber before making any switch.
• If no supply can be obtained: do not leave the patient without medicine. Contact the prescriber immediately to arrange an emergency prescription or urgent alternative supply.
• Enzyme inducers: check for any new medicines on the patient record that may interact; particularly antibiotics, antifungals, and newly started anticoagulants.

Ask the patient at the counter

• "Have you had any new seizures, or more seizures than usual, since your last supply?"
• Valproate patients of childbearing potential: "Are you pregnant, or could you become pregnant?": if yes, refer to the prescriber urgently and do not dispense until advice is obtained.

Lifestyle and surgical alerts

• Driving regulations apply following seizures. Any deterioration in seizure control must be reported to the prescriber promptly.
• Alcohol may increase sedation and can worsen seizure control.
• Any patient who is pregnant or planning pregnancy should be referred promptly to their specialist or prescriber for review.

Download the checklist