- When seizure free for 2-4 years - Normal neuro / EEG - Withdraw slowly over 6 months - 25-29% relapse in 1-2 yrs

- Lamotrigine - Zonisamide - Lacosamide - Perampanel Barbituates - GABA enhancers - Phenobarbital - Primidone - Lyrica (Pregabalin) - Gabitril (Tiagabine)

- Carbamazepine CYP 3A4 - Valproic Acid

Anti Epileptic Drugs Flashcards by Brianna Spahn

Seizure treatment steps

Determine type of seizure (Focal, Generalized/absence, tonic, clonic)
Choose AED based one
- Type of seizure
- Side effect profile
- Cost, Dosing preferences

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Stopping AED Tx

When seizure free for 2-4 years
Normal neuro / EEG
Withdraw slowly over 6 months
25-29% relapse in 1-2 yrs

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Excitation seizure

Too Much Go - GLUTAMATE, ASPARTATE

Ionic Currents: Inward Na+& Ca++

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Inhibition seizure

Not Enough Stop - GABA

Ionic Currents: Inward Cl-, Outward K+

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Warning for All AEDs

Suicidal ideation, thoughts, action

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1st Line Meds, Focal & Generalized (Tonic-Clonic)

Carbamazapine CYP3A4

Valproic Acid (Depakote)

Topiramate

Phenytoin (Dilantin)

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2nd Line Meds, Focal

Lamotrigine
Zonisamide
Lacosamide
Perampanel

Barbituates - GABA enhancers

Phenobarbital
Primidone
Lyrica (Pregabalin)
Gabitril (Tiagabine)

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2nd Line, General Tonic-Clonic

Perampanel
Primidone
Gabapentin

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1st Line, Lennox Gastaut Syndrome

Lamotrigine
Valproic Acid
Topiramate

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1st Line, Mixed

Carbamazepine CYP 3A4

- Valproic Acid

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Absence Tx, 1st & 2nd

1st

Valproic Acid
Ethosuxamide
Lamotrigine

2nd
- Clonazepam

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Myoclonic Tx

Keppra (Levetiracetam)

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1st line, Status Epilepticus

Diazepam
Lorazepam
Midazolam

Phenobarbital

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Carbamazepine, CYP 3A4

1st line for Focal, Generalized, Mixed

MOA: unclear - Na+ channel blocker

Also used for Trigeminal Neuralgia Pain

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Alternative use for Carbamazepine?

Trigeminal Neuralgia Pain

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Carbamazepine , CYP3A4

ADRs

COMMON
Drowsiness
Headache
Dizziness
Ataxia (loss of control of body movements)

N/V/D

Leukopenia
Hyponatremia
Rash

SERIOUS
Aplastic Anemia
Hepatitis
Pancreatitis 
SJS
Preg D (spina bifida)

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When is Carbamazepine CI?

Asian patients (increased SJS risk)

H/o bone marrow problems

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Lamotrigine

Na+ Channel blocker

(originally adjunctive) but in practice used 1st line
Focal / GCT, Lennox Gastaut

2nd line mono therapy Focal Seizures

Alt:
2nd line Bipolar

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Lamotrigine - Specific Warnings/ADRs

(Common ADRs same as Carba)

SJS in Pediatrics

Aseptic meningitis

Decreases OCP efficacy, progesterone

Valproate increases Lamotrigine effect

Valproic Acid (Depakote)

aka Valproate

GABA Enhancer

Indicated for EVERYTHING
- 1st line for Focal, Generalized, Mixed, Absence, Lennox Gastaut

Valproic Acid (Depakote) CI

Liver Disease

Pregnancy
- neural tube defects

Valproic Acid (Depakote)

COMMON ADRs

N/V
Fatigue
Dizziness
Hair loss
Weight gain
Depression
Hyperammonemia
Irregular periods
Bone loss

Valproic Acid (Depakote)

SERIOUS ADRs

Liver toxicity (esp Peds)

Pancreatitis

Thrombocytopenia

Teratogenicity

Topiramate

1st line Focal, General, Lennox Gastaut

Also for weight loss

Na+ channel

Topiramate Warnings

Angle Closure Glaucoma Hyperthermia, lack of sweating Metabolic acidosis Suicidal ideation SJS Cleft palate if used during pregnancy

Topiramate ADRs

Somnolence Ataxia (loss control body movements) Speech / Psychomotor / Memory Vision changes

Topiramate Drug Interactions

P450, 3A4, 2C19 ``` Topiramate concentration decreased by: Valproic Acid Phenytoin Carbamazepine Lamotigrine ``` *possible decrease in OCP efficacy*

Ethosuxamide (Zarontin)

Absence Seizures Ca+ channel blocker ADRs GI: N/V/D, abdo pain, decreased appetite CNS: drowsy, dizzy, headache, *pink-brown urine*

Ethosuxamide (Zarontin), serious ADRs

Liver, kidney, hemo problems SLE SJS Neuropsych

Phenytoin (Dilantin)

1st line Focal, GCT Slows Na+ recovery Very tight dosing, clearance decreases as dose increases Interacts with all the drugs

Phenytoin common ADRs

Sedation Dizziness Headache Impaired cognition / Confusion Slurred speech Decreased coordination Nystagmus

Phenytoin serious ADRs

Osteomalacia (long term) Lymphadenopathy Dermatitis (SJS, SLE)

Phenobarbital

Barbituate Prolongs GABA Use limited by side effects and drug interactions - 1st line alternative for Status - short term sedative

Phenobarbital Warnings

Addictive Hyperalgesia (increased sensitivity to pain) Respiratory depression

Phenobarb drug interactions

**induces hepatic microsomal enzymes** Decreases anticoagulant activity Enhances metabolism of exogenous steroids * Doxycycline - reduces half life, even 2 weeks after pheno DC'd* * Decreases OCP efficacy* CNS depressants ++

Phenobarbital ADRs

CNS depressant: - decreased cognition - resp depress - brady - fatigue - ED / libido - Anemia - Bone loss - Rash

Primidone

Barbituate - metabolized to phenobarbital in liver

Benzodiazepines

More GABA (more stop) Clonazepam (Klonopin) - Lennox Gastaut Diazepam (Valium) - Status Lorazepam (Ativan) - Status Midazolam (Versed) - Status

Gabapentin

Ca++ channel blocker - prevents presynaptic release Pain control (allodynia, hyperalgesia, peripheral pain, inflammatory pain) Used for peripheral neuropathy Bipolar

Gabapentin, Warnings / ADRs

Warnings - Pancreatic cancer, possible - Hypersensitivity ADRs - Sedation - Somnolence - Dizziness - Weight Gain

Pregabalin (Lyrica)

Son of Gabapentin > better absorbed, faster onset = lower dose and less side effects diabetic peripheral neuropathy postherpetic neuralgia Adjunctive therapy for adult patients with focal seizures fibromyalgia neuropathic pain associated with spinal cord injury

Pregabalin (Lyrica) ADRs

Dizziness Somnolence Weight gain Angioedema Peripheral Edema

Tiagibine (Gabitril)

More GABA - 2nd line for Focal Seizures - Anxiety - Bruxism - Migraine - Neuropathic pain

Tiagibine (Gabitril) Warnings / ADRs

Warnings - new onset seizure in pts without h/o epilepsy ADRs - Dizziness - Cognitive bleh - Depression - Aphasia - Asthenia (weakness) - Tremor - Nervousness

Vigabatrin (Sabril)

More GABA NOT REALLY USED BC CAN CAUSE PERMANENT VISION LOSS