Antiepileptic drugs

General Approach

• Partial seizure
  • Phenytoin
  • Carbamazepine (Tegretol)
  • Lacosimide, especially as add-on
• Generalized
  • Valproic acid, unless young woman
  • Lamotrigine (Lamictal)
  • Leviteracetam (Keppra)
  • Phenobarbital

Considerations

• Cost
  • Phenytoin
  • Valproic acid
  • Carbamazepine
• Rapidity of onset
  • Levitiracetam
  • Clobazam
  • Phenytoin
  • Valproic acid
• Pregnancy
  • Avoid valproic acid, phenytoin, topiramate, polypharmacy
  • Lamotrigine, leviteracetam are good?
• Type of seizure
  • Generalized
    • Valproic acid for boys
    • Lamotrigine for girls and women
  • Focal
    • Carbamazepine
• Enzyme induction by concurrent medications
• Renal or hepatic metabolism and excretion
• Side effect profile
  • Phenytoin
    • Hirsutism
    • Loading: hypotension, cardiac arrhythmias, and purple glove syndrome
  • Valproic acid
    • PCOS
    • Fatty liver
  • Skin reactions, especially with older medication

Initiation

• Loading
  • No need for loading unless in status epilepticus or high risk for recurrence
  • IV loading of phenytoin can cause ataxia
  • Other options can use IV valproic acid or levitiracetam, can use midazolam or propanol in the interim
• Titrate over several months