antiepileptics

Question 1

1st and 2nd line drugs for Focal seizures?

Answer 1

1st line: Carbamazepine or lamotrigine

2nd line: levetiracetam, oxcarbazepine, sodium valproate

Question 2

1st and 2nd line drugs for generalised tonic-clonic seizures?

Answer 2

1st: sodium valproate or lamotrigene
2nd: carbamazepine, clobazam, levetiracetam, or topiramate

Question 3

1st and 2nd line drugs for absence seizures?

Answer 3

1st line: sodium valproate or ethosuximide.

2nd line: lamotrigine

Question 4

1st and 2nd line drugs for myoclonic seizures? what drugs should be avoided and why?

Answer 4

1st line: sodium valproate. 2nd line: levetiracetam, or topiramate
(but increased SE).

avoid carbamazepine and oxcarbazepine—may worsen seizures.

Question 5

Drugs for tonic or atonic seizures?

Answer 5

Sodium valproate or lamotrigine.

Question 6

When should stopped AEDs be considered? How?

Answer 6

if patient been seizure free for >2 years - and after assessing risks and benefits for individual (eg need to drive). Needs to be done under specialist supervision.
Decrease dose slowly over 2-3 months - or greater than 6mo for benzodiazepines and barbituates

Question 7

When should AEDs be commenced?

Answer 7

After confirmed epilepsy diagnosis, greater than or equal to 2 seizures (unless risk of recurrence is high, eg structural
brain lesion, focal CNS deficit, or unequivocal epileptiform EEG), and following a detailed discussion of treatment options with the patient.

Question 8

Apart from AEDs, what other interventions can be considered?

Answer 8

Psychological therapies: Eg relaxation, CBT. - only as adjunct to medication
Surgical intervention: Can be considered if a single epileptogenic focus can be identified (such as hippocampal sclerosis or a small low-grade tumour) - neurosurgical resection - Alternatives: vagal nerve stimulation, deep
brain stimulation (DBS)

Question 9

Carbamazepine SEs?

Answer 9

leucopenia, diplopia, blurred vision, impaired

balance, mild generalized erythematous rash, SIADH

Question 10

Lamotrigene SEs? Dosage with other AEDs?

Answer 10

maculopapular rash, Stevens-Johnson syndrome or toxic epidermal necrolysis,

also diplopia, blurred vision, photosensitivity, tremor, aplastic anaemia

Question 11

levetiracetam SEs?

Answer 11

SE: psychiatric side-eff ects are common, eg depression, agitation.

Other SES: D&V, dyspepsia, drowsiness, diplopia, blood dyscrasias.

Question 12

Sodium valproate SEs?

Answer 12

teratogenic, nausea (common - take with food)

Other SES: liver failure (watch LFT especially during 1st 6 months), pancreatitis, hair
loss (grows back curly), oedema, ataxia, tremor, thrombocytopenia, encephalopathy
(hyperammonaemia).

Question 13

Phenytoin toxicity symptoms? SEs? monitoring?

Answer 13

Toxicity: nystagmus, diplopia, tremor, dysarthria,
ataxia

SE: reduced intellect, depression, coarse facial features, acne, gum hypertrophy, polyneuropathy, blood dyscrasias.

blood levels required for dosage

Question 14

AED pregnancy advice?

Answer 14

Advice women of child-bearing age to take folic acid 5mg/d
Strictly avoid sodium valproate and polytherapy prior to conception and during
pregnancy (lamotrigine is preferred but transition needs to be planned).
• Advise that most AEDS except carbamazepine and valproate are present in
breast milk. Lamotrigine is not thought to be harmful to infants.
• Discuss contraceptive methods, bearing in mind that: enzyme-inducing AEDS
make progesterone-only contraception unreliable, and oestrogen-containing
contraceptives lower lamotrigine levels—an increased dose may be needed to
achieve seizure control.

Question 15

Which AEDs are not present in breast milk?

Answer 15

carbamazepine and valproate

Lamotrigine is not thought to be harmful to infants.

Question 16

Which are the major enzyme inducing AEDs?

Answer 16

carbamazepine, phenytoin, phenobarbital and primidone