You are on page 1of 5

There is no formula to choose which seizure medicine to use for a particular patient.

No one medicine dominates for effectiveness, and all have various side effects. Doctors and patients choose AEDs after considering which side effects should be avoided in particular cases, convenience of use, cost and physician experience. An important start is to now which AEDs wor for which seizure types. The narrow spectrum AEDs mostly wor for specific types of seizures !such as partial, focal, or absence, myoclonic seizures". #road spectrum AEDs additionally have some effectiveness for a wide variety of seizures !partial plus absence myoclonic seizures". $ome types of seizure are difficult to treat with any AED. !%o here to learn what these seizures types are". Narrow-spectrum AEDs: & phenytoin !Dilantin" & phenobarbital & carbamazepine !Tegretol" & oxcarbazepine !Trileptal" & gabapentin !Neurontin" & pregabalin !'yrica" & lacosamide !*impat" & vigabatrin !$abril" Broad-spectrum AEDs: & valproic acid !Depa ote" & lamotrigine !'amictal" & topiramate !Topamax" & zonisamide !(onegran" & levetiracetam !)eppra" & clonazepam !)lonopin" & rufinamide !#anzel"

General Points
+. Brand vs. generic. Every medicine has a brand and a generic name. The generic usually is cheaper, sometimes by ,uite a lot. -or medicines introduced in recent years, patent !or .mar et exclusivity/" protection may bloc the sale of generic versions. A generic medicine usually wor s well, but it may not generate the same blood levels as does the brand name or an alternative generic medicine. Therefore, with changes of pill manufacturers, the blood levels can change. This may produce brea through seizures or side effects. The most important concern when ta ing generic drugs is to be sure the tablets are made by the same manufacturer for each refill. $witching from one generic manufacturer to another could result in different amount of active drug in each pill. The current author supports the right of the patient and doctor to now about medication substitution and consider whether generic substitution is safe. 0. Starting schedule: 1any AEDs have to be started slowly to minimize side effects, event though this delays helping the seizures. The titration !starting" schedules are those of the author, and may be slower than is the schedule recommended in the pac age insert. Dosages are all for adults. 2hildren are treated on the basis of their weight !mg per g dosing basis". 3. Monotherap : $ome AEDs have approval for monotherapy !to be used alone" and others only as ad4unctive !add&on" therapy to another AED. This reflects what testing evidence has been presented to the -DA & not all AEDs have gone through the re,uired two clinical studies to show effectiveness in monotherapy. AEDs not proven effective in monotherapy still probably wor well as single medications and are used that way by epilepsy doctors on a case&by&case basis where the benefit seems to exceed the ris . 5. Blood levels: Target blood levels are broad guides to clinical use. Actual blood levels differ for different laboratories. The desirable level depends upon the type and number of seizures, side effects, ta ing one vs. multiple drugs and other clinical factors. 6. Side e!!ects: $ide effects listed below are a brief compilation of the most common and most worrisome, not a full list. Every seizure medicine can sometimes cause side effects of fatigue, dizziness, unsteadiness, blurry vision, stomach upset, headaches, and reduced resistance to colds, memory and thin ing problems. 7eight gain tends to occur with



<. >.

valproic acid !Depa ote", gabapentin !Neurontin", pregabalin !'yrica" and carbamazepine !Tegretol, 2arbatrol". 7eight loss tends to occur with topiramate !Topamax", zonisamide !(onegran" and felbamate !-elbatol". These are not mentioned separately in each section, unless they are especially common with the medicine. Detailed information is provided by the pharmacy as a pac age insert for new prescriptions and refills. E!!ects on internal organs: All seizure medicines can cause problems with blood counts !white cells, red cells and platelets", or liver or other internal organs, so doctors usually order blood tests to screen for these problems. #lood can be tested when starting a medicine to get a baseline, after a few months on the drug, every few months to yearly thereafter, then at individually determined times. The pac age insert often has recommendations, but there are no universal rules about when to test blood. All seizure medicines can produce either mild or severe allergic reactions. 9ne, called the hypersensitivity syndrome, produces fever, rash, fluid accumulation, swollen lymph nodes, possible liver in4ury and confusion Suicide warning: The ;$ -DA has re,uired a suicide warning on all seizure medications as a general class. All people ta ing them should be aware of and report any serious depression or suicidal thin ing to their doctor, but the actual ris for suicide due to AEDs is ,uite low. Mechanism: 1echanisms of action in the brain for antiepileptic drugs are described in simple form= most AEDs have multiple mechanisms of action to bloc seizures. Not a cure: Although AEDs are called .antiepileptic,/ they do not cure epilepsy, but 4ust suppress seizures while the medications are in the body.

"ndividual Antiepileptic Drugs #AEDs$% alpha&eticall

car&ama'epine #(egretol% )ar&atrol$: A favorite partial seizure medicine in the developed world. 2arbamazepine affects sodium channels, and inhibits rapid firing of brain cells. 'ong& acting forms such as 2arbatrol or Tegretol&?@ can be given once a day. Aotential side effects include %B upset, weight gain, blurred vision, low blood counts, low blood sodium !hyponatremia". 2arbamazepine causes a rash rate of a few percent, sometimes even the dangerous rash called $tevens&Cohnson syndrome. Aeople of Asian descent with D'A&#E+6F0 antigen are more at ris . Typical adult dose is 5FF mg tid. B start my patients with 0FF mg bid and each wee , and increase by 0FF mg daily to about 5FF mg three times a day. *iew information on 2arbamazepine here and information about 2arbatrol here. clona'epam #*lonopin$: 2lonazepam is a member of the drug class nown as benzodiazepines, to which diazepam !*alium", lorazepam !Ativan", clorazepate !Tranxene", alprazolam !?anax" also belong. #enzodiazepines are used as anti&seizure drugs, sedatives, tran,uilizers and muscle relaxants. #enzodiazepines increase the effectiveness of %A#A, the brainGs main inhibitory neurotransmitter. 2lonazepam is more long&acting against seizures than are diazepam or lorazepam. $ide effects of clonazepam include sedation, thin ingHmemory impairment, mood changes, addiction. 1ore so than most, its effects wear off over time. A typical adult dose is F.6& +.F mg three times a day. B usually start my patients with F.6 mg at night, and if they are not too sleepy the next day, increase to F.6 mg twice a day. A wee later, if seizures persist, B will increase to F.6 mg three times a day. $ee information on 2lonazepam here. ga&apentin #Neurontin$: %abapentin has the reputation of being a safe but not particularly powerful AED. The effectiveness criticism probably is because it is often prescribed at too low a dose. The drug probably wor s by influencing transport of %A#A and effects on calcium channels. Bt has no drug interactions, is not metabolized in the liver and it does not bind to blood proteins. $ide effects are unsteadiness, weight gain, fatigue, dizziness. Typical adult dose is 3FF&

8FF mg three times a, but doses can be up to +0FF mg three times a day. B often start at 3FF mg per day, sometimes in one dose or with +FF mg pills, and increase over a month or two to the full dose. %abapentin often is used also for chronic pains of certain types. $ee information on gabapentin here. lacosamide #+impat$: 'acosamide is a new !0FF>" antiepileptic drug , for partial and secondarily generalized seizures. Bt is chemically related to the amino acid, serine. *impat bloc s sodium channels !but in a different way from other seizure medicines", and this bloc reduces brain excitability. $ide effects include dizziness, headache, nausea or vomiting, double vision, fatigue, memory or mood problems. *impat may affect the internal organs, blood counts or heart rhythm, but these potentially serious side effects are infre,uent. The recommended starting dose is 6F mg twice daily, increased each wee by an extra +FF mg, to the recommended maintenance dosage of +FF&0FF mg twice a day. $ee information on *impat. lamotrigine #,amictal$: A broad&spectrum alternative to *AA, with a better side effect profile. Dowever, 'T% may not be as effective for myoclonic seizures. 'amotrigine wor s by several mechanisms including bloc ing release of glutamate, the brainGs main excitatory neurotransmitter. Bt has the usual side effects of dizziness and fatigue, usually mild cognitive !thin ing" impairment. $evere medical side effects are unusual. The practical side effect issue is rash, occurring in several percent of people who ta e it, especially if the dose is increased too fast. Therefore, it ta es a couple of months to get up to the typical adult dose of 0FF mg twice a day. B usually start my patients at low doses, adding one 06 mg pill daily each wee on a two& times&a&day schedule until ta ing +FF mg twice a day. Bf there is no rash at that time, one is unli ely. B then switch my patients to +FF mg pills and increase to 0FF mg twice a day over the next few wee s. This is slower than the pac age insert suggested starting dose, however, a slow starting dose is especially important if the patient also ta es valproic acid !Depa ote", to reduce ris for rash. 'amotrigine is also used for mood stabilization. $ee information on 'amictal. levetiracetam #*eppra$: 'evetiracetam is one of the more used medicines in seizure clinics because it probably is effective for a broad&spectrum of seizures types, has a relatively low incidence of causing thin ingHmemory problems, and can be started at 6FF mg twice a day, which is an effective dose. Bt has no drug interactions, is not metabolized in the liver and it does not bind to blood proteins. The most common side effects are dizziness, fatigue, insomnia, but the more troublesome problem can be irritability and mood changes. This may occur to some degree in up to a third of those ta ing the medicine. A typical adult dose is 6FF & +6FF mg twice a day. B usually start my patients with 06F mg twice a day and increase the next wee to 6FF mg twice a day, then the next wee to +FFF mg in the am plus 6FF mg in the pm, then the wee after to +FFF mg twice a day. This is slower than the pac age insert suggested starting dose. $ee information on )eppra. lora'epam #Ativan$: 'orazepam is similar to clonazepam in dosage and action, but it is not as long&acting. Bt is usually used as a Irescue medicationG for patients who fre,uently have clusters of seizures. Bt wor s reasonably ,uic ly when ta en orally and anti&seizure effect lasts for 0&8 hours. Typical adult dose is F.6&0.F mg orally or as needed. A lorazepam concentrate, 0 mg per ml, can be ta en as + ml li,uid under the tongue in urgent situations. o-car&a'epine #(rileptal$: $lightly different from carbamazepine, it is at least as effective, and may have fewer side effects, except for more ris for low blood sodium !hyponatremia". Bt is more expensive than generic carbamazepine. A typical adult dose is 8FF mg twice a day. B start my patients with +6F mg twice a day, and increase by +6F mg daily each wee . This is slower than the pac age insert suggested starting dose. An immediate switch from carbamazepine to full&dose oxcarbazepine is possible in some cases. $ee information on Trileptal.

pheno&ar&ital #,uminal$: The old&timer= very inexpensive and effective in a single daily dose. Ahenobarbital increases the effect of %A#A, the main inhibitory neurotransmitter in the brain. 7atch for sedation, thin ingHmemory problems and depression. Ahenobarbital can cause long& term bone problems. Ahenobarbital is mildly addictive and re,uires slow withdrawal. During pregnancy, there is a significant rate of birth defects. Typical adult dose is around +FF mg per day. B start my patients with 3F mg pills, 0 or 3 at bedtime, to allow for future dosage flexibility. The target serum level is +F&5F mcg per ml. $ee information on phenobarbital. phen toin #Dilantin$: The most used AED by general physicians in the ;$, less so by epilepsy doctors, because of the side effects. Ahenytoin alters brain cell sodium channels, which has the effect of limiting rapid firing of the brain cells. Bt is inexpensive. 2ommon side effects are unsteadiness and moderate cognitive problems. There are long&term potential cosmetic !bodyHface hair growth, s in problems", and bone problems !osteoporosis". Ahenytoin causes a rash rate of a few percent, sometimes even the dangerous rash called $tevens&Cohnson syndrome. Typical adult dose is 3FF&5FF mg per day, usually with +FF mg pills. Ahenytoin can be started ,uic ly in an emergency with intravenous administration, or a large dose of capsules if an immediate effect is re,uired. $mall changes in phenytoin dose can cause large changes in serum drug levels, so the blood levels can be hard to regulate. The target serum level is +F&0F mcg per ml. $ee information on phenytoin. prega&alin #, rica$: A relative of gabapentin, it may be better, and can be given twice a day. $ome believe that it is more effective against seizures than is gabapentin. Aregabalin has no drug interactions, no liver metabolism, no protein binding, and similar side effects to gabapentin. Typical adult dose is +6F & 8FF mg bid. B usually start my patients with 6F mg daily, adding 6F mg each wee on a twice a day basis until ta ing 3FF & 8FF mg per day. This is slower than the pac age insert suggested starting dose, but avoid sedation. Aregabalin often is used also for chronic pains of certain types. $ee information on 'yrica. ru!inamide #Ban'el% "novelon in Europe$: #anzel is approved for add&on treatment of children age 5 and older and adults with the 'ennox %astaut $yndrome !see http=HHwww.epilepsy.comHEAB'EA$JHepilepsyKlennoxgastaut ". This syndrome can include seizure types such as atonic !drop" seizures, tonic !stiffening" seizures, myoclonic !brief 4er ing" seizures, or staring !absence" seizures, as well as partial seizures. #anzel wor s on sodium channels in brain cells, in a way to ma e them less excitable. 2ommon side effects include headache, dizziness, fatigue and sleepiness, double vision and tremor !trembling". Aeople who have the .short LT syndrome,/ a rare heart rhythm irregularity, should not ta e #anzel. The drug comes as 0FF and 5FF mg tablets. 2hildren will usually be started at doses of approximately +F mgH gHday administered in two e,ually divided doses. Dosing can increase by adding additional +F mgH g amounts every two days, until the child is ta ing 56 mgH gHday or a maximum of 30FF mgHday, divided into two doses each day. $ee information on #anzel. topiramate #(opama-$: A good broad&spectrum AED !i.e., treats all types of seizures". Topiramate has several mechanisms, including bloc ing the enzyme carbonic anhydrase, which affects the acidity of brain tissue. 1ore acidity !to a point" suppresses seizures. $ide effects include thin ing and memory problems in about +H3rd, renal stones in +&0M, rare cases of glaucoma !increased eye pressure" and weight loss. Typical adult dose is +6F&0FF mg twice a day. B usually start my patients with one 06 mg pill daily, adding another pill each wee on a two&times&a&day schedule until ta ing +FF mg twice a day. Bf there are no significant side effects, B then switch my patients to +FF mg pills and increase to 0FF mg twice a day over the next few wee s. Topiramate also is used for migraine headache prevention. $ee information on Topamax.

valproic acid #Depa.ote$: This is the standard broad&spectrum AED !treats all types of seizures" and no other AED is more effective for generalized seizure types. *AA has effects on %A#A !at least in very high doses", and a neurotransmitter called NAJ to bloc seizures, and maybe also on calcium channels. *AA has significant side effects= weight gain, tremor, hair loss, %B upset, blood count decreases, hepatic or pancreatic in4ury, bone wea ness over time !osteoporosis", birth defects in up to +FM !folic acid can help to prevent them". Typical adult dose is 06F mg & 6FF mg three times a day, but dose can be higher. An extended release form can be ta en once a day. $ee information on valproic acid. viga&atrin #Sa&ril$: At time of this writing, vigabatrin is approved in the ;$, but official pac age insert information has not become available. *igabatrin is a .designer drug,/ made to bloc metabolism of %A#A, the brainGs main inhibitory neurotransmitter. $abril has been used for over a decade in many countries, and it is effective for partial seizures, with or without secondary generalization. Bt also may be very effective for infantile spasms, a serious type of seizures in young children. @elease in the ;$ was delayed because the drug is toxic to the retina of the eye in up to 3FM of people who ta e it long&term. This toxicity can result in permanent loss of peripheral vision. @egular vision testing is recommended for all people on this drug. A typical regimen begins with 6FF mg twice a day, and can increase over a month or two to +6FF mg twice a day. 'onisamide #/onegran$: (onisamide is rather similar in its coverage and side effects to topiramate, except glaucoma is not usually listed. $ome find less cognitive impairment than with topiramate but this is individual and dose&dependent. Typical adult dose is +FF&3FF mg twice a day. B usually start my patients with one 06 mg pill daily, adding 06 mg each wee on a two& times&a&day schedule until ta ing +FF mg twice a day. Bf there are no significant side effects, B then switch my patients to +FF mg pills and increase to 0FF mg twice a day over the next few wee s. $ee information on zonisamide. 0thers: acetazolamide !Diamox", diazepam rectal gel !Diastat", ethosuximide !(arontin", felbamate !-elbatol", primidone !1ysoline", tiagabine !%abitril" can be searched individually on .