Anti seizure medications

Anti seizure medications DEFAULT

Seizure Medications

Continuing Education Activity

The mainstay treatment strategy for seizures is medication management. However, much like the prescription of any other pharmaceutical agent, a clinician must balance efficacy with adverse events, and provide consideration for cost, drug interactions, patient preference, and availability. This activity outlines the indications, mechanisms of action, methods of administration, important adverse effects, contraindications, and monitoring, of various seizure medications, so providers can direct patient therapy in treating indicated disorders as part of the interprofessional team with seizure medications, with a basis on the current knowledge for optimal utilization.

Objectives:

  • Identify the various classes of anti-seizure medications and their mechanisms of action.

  • Review the indications for therapy initiation by seizure drug subclass.

  • Describe the contraindications and adverse effects of the various agents in the seizure medication classification.

  • Explain the importance of improving care coordination among the interprofessional team to enhance the delivery of care for patients who can benefit from therapy with seizure medications.

Access free multiple choice questions on this topic.

Indications

The mainstay treatment strategy for seizures is medication management. However, much like the prescription of any other pharmaceutical agent, a clinician must balance efficacy with adverse events, while considering cost, drug interactions, patient preference, and availability. This article is intended to provide a general overview of seizure medications and the current knowledge base for optimal utilization.[1][2][3]

The American Academy of Neurology (AAN) and the American Epilepsy Society offered recent guidelines on the initiation of seizure medications after a first unprovoked seizure in an adult. The focus is predominantly on an individualized approach, with patient autonomy at the forefront. Before making any decisions, factors that may increase risk should be identified and include abnormal brain imaging, abnormal electroencephalogram (EEG), and the presence of nocturnal seizures. Patients should understand that the risk of seizure recurrence is greatest within the first 2 years (21% to 45%) and that this risk may be mitigated with the initiation of medications. However, adverse events of anti-seizure medications, though most frequently mild and reversible, should be reviewed and discussed in detail.

Of note, certain seizure medications have been used off-label for a variety of other indications, including but not limited to:

  • Anxiolytics: Pregabalin, clonazepam, clobazam

  • Migraine relief: Zonisamide, valproic acid, topiramate

  • Mood stabilizer: Valproic Acid, lamotrigine, carbamazepine

  • Neuropathic pain relief: Pregabalin, gabapentin, carbamazepine

  • Weight loss: Zonisamide, topiramate

  • Antiparkinsonian agent: Zonisamide

Mechanism of Action

Anti-epileptic drugs (AEDs) are numerous. There are a variety of mechanisms of action, and some AEDs possess multiple mechanisms of action. Although precise mechanisms of some drugs remain elusive, anti-seizure medications tend to be grouped by their principal mode of action. A brief review of some of the major drugs on the market is provided below.

Some AEDs act on the sodium channels by either blocking their repetitive activation (phenytoin, carbamazepine) or by enhancing their slow inactivation (lacosamide). Others work on calcium channels by blocking either T-type calcium channels (ethosuximide, valproic acid) or the N- and L-type calcium channels (zonisamide). Lamotrigine works by blocking sodium channels, blocking N- and L-type calcium channel, and modulating H-current. Topiramate works by blocking sodium channels, alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA) receptors, and by inhibiting carbonic anhydrase. Other mechanisms through which AEDs act are by enhancing gamma-aminobutyric acid (GABA)-A receptors (phenobarbital, benzodiazepines), blocking N-methyl-D-aspartic acid (NMDA) receptors (felbamate), and opening neuronal potassium channels (ezogabine).[4] More detailed descriptions of some of these drugs are provided in the following paragraphs. 

Carbamazepine (CBZ) is used for focal and generalized seizures. It is also used for patients with bipolar disorder and trigeminal neuralgia. By inhibiting voltage-gated sodium channels, CBZ reduces neuronal firing. It is metabolized by the cytochrome P450 system and is a strong inducer of these hepatic enzymes. Common side effects include gastrointestinal upset, hyponatremia, rash, itch, drowsiness, dizziness, blurred vision, and headache. Rare but dangerous side effects include Stevens-Johnson syndrome, toxic epidermal necrolysis, leukopenia, and aplastic anemia (pancytopenia). 

Oxcarbazepine is structurally similar to CBZ and thus wields a similar mechanism of action. It is also comparable to CBZ in terms of efficacy for focal and secondarily generalized tonic-clonic seizures. Patients may experience dizziness, headache, ataxia, nausea, rash, double vision, and/or hyponatremia. The latter effect is thought to be secondary to the syndrome of inappropriate secretion of antidiuretic hormore (SIADH) and may occur in 25-75% of patients. 

Phenytoin is one of the oldest anti-seizure medications and is still widely used for focal and generalized seizures. It is also administered for status epilepticus. In addition, practitioners may invoke phenytoin as a second-line agent for patients with mixed seizure types (e.g., tonic-clonic and myoclonic). As mentioned, phenytoin blocks voltage-gated sodium channels, but other possible mechanisms revolve around decreased synaptic transmission, smaller changes in ionic gradients involving the sodium-potassium ATPase pump, and inhibition of calcium-calmodulin phosphorylation. Of note, phenytoin is a broad spectrum inducer of the CYP system and, therefore, may reduce the effectiveness of many forms of hormonal oral contraception (OCP) medications. Major adverse effects include gingival hyperplasia, body hair increase, folic acid depletion, rash, and worsening bone density. Patients should also be counseled regarding the possible development of confusion, ataxia, double vision, and neuropathy with long-term usage. 

Lacosamide stabilizes hyperexcitable membranes and inhibits repetitive neural firing via the slow inactivation of voltage-gated sodium channels. Another possible mechanism may involve binding to collapsin response mediator protein 2 (CRMP2), which has been implicated in epileptogenesis. Lacosamide is used as monotherapy or adjunct therapy for focal-onset seizures in patients aged 4 years and up. It tends to be tolerated decently well, with dizziness, ataxia, and nausea being the most typically encountered adverse effects. Importantly, dose-dependent PR interval prolongation on electrocardiogram (EKG) is a well known effect, and so EKG monitoring is recommended alongside initiation of therapy. 

Phenobarbital is another very old drug. It is used for generalized and focal seizures, but its sedating properties make it difficult to use in the modern clinical realm. Regarding mechanism, phenobarbital is a barbituate and binds to the GABA-A receptor, prolonging its open state to allow for more chloride influx and consequent cellular hyperpolarization. It is a potent inducer of the CYP system and thus can decrease serum levels of other drugs metablized by this pathway. 

Vigabatrin is an inhibitor of an enzyme that metabolizes GABA (GABA transaminase), thereby elevating GABA concentrations within the central nervous system. Vigabatrin is used adjunctively for refractory focal seizures, but it can also be used as monotherapy in this setting. It is also useful in the pediatric world for infantile spasms, particularly in children with tuberous sclerosis complex. Patients should be precautioned regarding possible vision loss. The drug can also lead to MRI abnormalities (but without clear neurologic deficits), fatigue, dizziness, and headache. 

Topiramate has several modes of action, including blockage of voltage-gated sodium channels, GABA transmission enhancement, and NMDA receptor antagonization. It also blocks carbonic anhydrase to a modest extent. Topiramate is used as monotherapy in both pediatric and adult medicine for focal-onset and primary generalized tonic-clonic seizures (ages 10 and up). The drug can also be used as adjunctive therapy for focal seizures or in patients with Lennox-Gastaut syndrome (ages 2 and up). Patients may commonly experience weight loss, impaired cognition, and difficulties with expressive language. Some patients may experience fatigue, depression, headache, and/or paresthesias. Metabolic acidosis with tachypnea and/or calcium phosphate nephrolithiasis (kidney stones) may also occur. 

Valproate (valproic acid, VPA) is another broad spectrum medication used to treat both focal and generalized seizures. Similar to topiramate, it possesses multiple mechanisms of action, including voltage-gated sodium channel inhibition, augmentation of GABA concentrations, and mild inhibition of T-type calcium currents (but not to the extent of ethosuximide). Valproate is metabolized by the liver and is an inhibitor of CYP enzymes. It should be used with caution in patients with hepatic insufficiency and should be avoided altogether in patients with urea cycle disorders due to high risk of hyperammonemia. Parenthetically, combining topiramate and valproate can lead to increased levels of ammonia. This combination should be closely monitored if encountered in clinical practice. With that said, topiramate is not alone in this regard; other carbonic anhydrase inhibitors, enzyme-inducing anti-seizure drugs, and antipsychotic medications can increase the risk of hyperammonemic encephalopathy in the setting of VPA use. Other general side effects of VPA include nausea/vomiting, tremor, easy bruising, weight gain/insulin resistance, metabolic syndrome, and subclinical hypothyroidism. Rarely, VPA can cause acute hepatocellular injury with jaundice or acute pancreatitis. VPA should be avoided during pregnancy, as teratogenic neurotoxicity has been observed. 

Levetiracetam's precise mechanism is not clear, but studies have linked its effectiveness to the binding of synaptic vesicle protein 2A (SV2A). It encompasses a very broad spectrum in terms of its efficacy and is used as adjunctive therapy for focal-onset seizures in children and adults, myoclonic seizures in patients with juvenile myoclonic epilepsy (ages 12 and up), and primary generalized tonic-clonic seizures (ages 6 and up) in patients with idiopathic generalized epilepsy. The drug is uniquely metabolized independent of the hepatic CYP system, and it does not induce CYP enzymes like phenytoin, phenobarbital, and carbamazepine. Importantly, levetiracetam does not necessitate a prolonged titration period like other drugs (e.g., lamotrigine with its risk of Stevens-Johnson syndrome). Levetiracetam is extremely well-tolerated, with common adverse effects revolving around behavioral disturbances, drowsiness, dizziness, and upper respiratory infections. 

In summary, it is now abundantly clear that anti-seizure medications wield disparate mechanistic profiles, but they all effectively suppress epileptic seizures in one way or another. Accordingly, grouping the drugs together by mechanism is a very helpful organizing principle. From this viewpoint, it may become easier to appreciate that some drugs have different efficacy profiles for different seizures types and epilepsy syndromes. Ethosuximide is an exception with its specific limited use with respect to absence seizures, but almost all of the other available medications listed above have potential use against generalized and focal seizures. [5]

Administration

Seizure Types

After the diagnosis of epilepsy, choosing of an AED is largely dependent on the classification of the seizure type. In the most general sense, seizures can be classified as either partial or generalized. Partial seizures can be further broken down into those that do not affect awareness (simple partial) or those that do (complex partial).

Simple partial seizures affect focal areas of the brain that, in turn, cause focal neurological findings like loss of motor function in one limb, sensory dysfunction in a specific body region, or changes to vision or speech, without affecting awareness of the event. Complex partial seizures are similar but do include brief moments of confusion that quickly resolve once the seizure has ended.

Generalized seizures affect the entire body and can exist as tonic-clonic seizures (where muscles stiffen initially, which is followed by jerking and spasming of the body), absence seizures (where individuals may stare off into space, and there is a brief lapse in awareness, often confused with daydreaming), and atonic seizures (where there is a sudden loss of muscle tone, frequently resulting in falls).

The International League Against Epilepsy (ILAE) recommends that epilepsy be diagnosed when any of the following exist: a history of two unprovoked seizures at least 24 hours apart, or an unprovoked seizure when the risk for a subsequent seizure is greater than 60% after two unproved seizures over the subsequent 10 years, or seizures that are part of an epilepsy syndrome.

Initiation of Antiepileptic Drugs

AEDs can be broken down into two categories: broad-spectrum and narrow-spectrum. Broad-spectrum AEDs treat a wide variety of seizure types, as the name suggests, and are a good initial choice, especially when the classification of seizure type is uncertain. These AEDs include but are not limited to levetiracetam, lamotrigine, zonisamide, topiramate, valproic acid, clonazepam, perampanel, clobazam, and rufinamide.

Narrow spectrum AEDs primarily are for the treatment of focal or partial seizures. These include but are not limited to lacosamide, pregabalin, gabapentin, carbamazepine, oxcarbazepine, ezogabine, phenytoin, and vigabatrin.

Monotherapy is the ideal pathway for the treatment of seizures, but newer AEDs have had difficulty obtaining FDA approval as a monotherapy agent due to the difficulty of achieving approval requirements. However, anecdotally, and by examining the current evidence base, second-generation AEDs appear to be an appropriate choice, as they have demonstrated similar efficacy when compared to older AEDs and may be better tolerated.

One large randomized trial, the Standard and New Antiepileptic Drugs (SANAD) trial, demonstrated some comparative advantages of certain AEDs when treating focal or generalized epilepsy. In the end, when comparing valproate, lamotrigine, or topiramate for generalized seizures, they recommended valproic acid as their first-line choice. Additionally, when comparing carbamazepine, gabapentin, lamotrigine, oxcarbazepine, and topiramate for focal seizures, lamotrigine was cited as the first-line choice.

Of note, regarding partial onset seizures specifically, perampanel, lacosamide, brivaracetam, and eslicarbazepine acetate are a few of the recently FDA-approved seizure medications for monotherapy.

Discontinuation

When to discontinue AEDs is less clear. In children, consensus recommendations appear to be after two years of remaining seizure free. However, in adults, some research has estimated the risk of seizure recurrence immediately after cessation of AEDs at the 2-year mark at 30%. The risk appears to diminish with time if an individual continues without further seizures. Taking this into account, it is apparent why guidelines in adults are more conservative and recommend a seizure-free period of 2 to 5 years while advising against driving for three months after AED cessation.

Adverse Effects

Patients should be taught that adverse events with anti-seizure medications, according to the AAN, may range from 7% to 31%, but are mostly mild and reversible. In general, it is important to review the specific medication insert for a complete list of adverse events.[6][7][8]

Of the more mild and common side effects, patients should be advised to monitor for headaches, fatigue, dizziness, blurry vision, nausea, weight gain or loss, mood disorders, and neurocognitive problems. The potential for allergic reactions is present amongst all medications and should be monitored upon initiation.

With chronic use, many AEDs carry a side effect of osteoporosis, and general recommendations are to supplement diets with calcium and vitamin D, while encouraging routine exercise habits.

Of the more serious side effects, Stevens-Johnson syndrome, agranulocytosis, aplastic anemia, hepatic failure, pancytopenia, multiorgan hypersensitivity, psychosis, and lupus syndrome have all been reported. Although the risk for suicidality is low, the FDA has required all AEDs to carry a suicide warning.

Also of concern are drug-drug interactions, which occur most commonly with the older generation of AEDs, as they can affect hepatic enzymes (e.g., the cytochrome P450 system). If these hepatic enzymes are induced, it can lead to the rapid metabolism of other medications, potentially leading to their subtherapeutic levels in the body. If, on the other hand, hepatic enzymes are inhibited, toxic levels of medications can be reached due to impaired breakdown through the liver. For example, carbamazepine, phenytoin, and phenobarbital are liver enzyme inducers and can increase the metabolism of concomitantly prescribed drugs like warfarin. In contrast, valproate is a liver enzyme inhibitor.  

Both inducing and inhibiting medications can raise significant concern when managing certain comorbid conditions where therapeutic doses of medications are of the utmost importance, including HIV, cancer, endocrine disorders, and cardiovascular disease.

Contraindications

A contraindication to most medications, in general, is a prior history of hypersensitivity or allergic reaction to that medication. Other contraindications exist but are more drug-specific, including hepatic failure, certain blood diseases, narrow-angle glaucoma, and familial short QT syndrome, to name a few.

Valproic acid and felbamate are associated with hepatotoxicity and, therefore, contraindicated in patients with hepatic failure. The liver metabolizes many others, and dosage adjustments need to be made before initiation.

Similarly, those with renal impairments need to adjust dosing when AEDs are primarily excreted via the kidneys. Adjustments can be made using the glomerular filtration rate. Hemodialysis also may require dosing adjustment to ensure the medication remains in the respective therapeutic range.

Likewise, because of variability in metabolism and excretion rates, caution must be exercised in children and the elderly.

Regarding pregnancy, guidelines proffered by the AAN in 2009 report that women should remain on their current AED, as switching medications can increase the risk of breakthrough seizure, and adding another AED increases the risk of congenital disabilities. Folic acid should be supplemented for any woman of childbearing age, especially those considering becoming pregnant. If possible, optimization of the medication regimen, by identifying the lowest effective dose with the least amount of medications, is ideal. Women who experience their first seizure during pregnancy should follow the same management strategy as if they were not pregnant.

Through the duration of the pregnancy, serum drug levels should regularly be monitored, and dosages titrated or adjusted to within therapeutic ranges.

Unfortunately, there is insufficient research into comparative efficacy and teratogenicity for recommendations of specific AEDs in pregnancy. However, valproic acid deserves special mention as it is contraindicated in pregnancy due to consistent evidence of teratogenicity, including dose-dependent effects on IQ, adaptive functioning, increased risk of ADHD, and increased risk of major congenital malformations.

As benefits are believed to outweigh risks, the consensus remains that AEDs can continue to be taken while breastfeeding. However, measurable levels can be found in breastmilk, and available research has not determined what risk this poses to newborns.[9][10][11]

Monitoring

Once administered, monitoring of serum medication levels is recommended to establish a therapeutic baseline and assess for toxicity. If the patient remains stable, these levels can be checked yearly, along with a complete blood count, a comprehensive metabolic panel, and liver function testing.

Toxicity

Toxic symptoms in AEDs are idiosyncratic and are believed to occur more frequently in the first-generation AEDs. One such example is carbamazepine, a commonly implicated first-generation AED in acute or chronic toxicity. Possible symptoms may include ataxia, dystonia, sinus tachycardia, hyperthermia, coma, arrhythmias, respiratory depression, and death. Another example is valproic acid, which can have toxic effects that include metabolic and hematological disruption, pancreatitis, central nervous system (CNS) depression, optic nerve atrophy, respiratory depression, cardiopulmonary arrest, brain edema, and coma.[12][13][14]

Treatment can range from supportive measures to high-flow hemodialysis, plasmapheresis, or charcoal hemoperfusion.

Patients should be educated before initiating any AED to alert treating physicians when adverse events are encountered. It is also important to note that therapeutic reference ranges are considered guidelines, and levels outside of the range do not necessarily indicate toxicity or a need to adjust dosing. However, if a given clinical picture correlates with elevated serum drug levels, then, indeed, treatment is warranted.

Enhancing Healthcare Team Outcomes

Once a patient has been started on anti-seizure medications, education of the patient is vital. In addition to the prescribing practitioner, both the patient's nurse and pharmacist should educate the patient on adherence on medication compliance. Further, injury is not uncommon during a seizure, and the family has to be educated about seizure precautions surrounding activities like driving and swimming. Patients with a diagnosis of seizures should not undertake unsupervised activities in the water or work at heights. Depending on the frequency of seizures, some patients may not be allowed to drive. Because most anti-seizure medications have side effects, the patient must be told to follow up with the primary caregiver and be monitored closely. Finally, patients should be cautioned against changing the dose frequency or timing, without first speaking to the healthcare provider. [15][16][17](Level V)

References

1.

Kassahun G, Moges G, Demessie Y. Assessment of Patients' Adherence to Antiepileptic Medications at Dessie Referral Hospital, Chronic Follow-Up, South Wollo, Amhara Region, North East Ethiopia. Neurol Res Int. 2018;2018:5109615. [PMC free article: PMC6151205] [PubMed: 30271635]

2.

Kanner AM, Ashman E, Gloss D, Harden C, Bourgeois B, Bautista JF, Abou-Khalil B, Burakgazi-Dalkilic E, Park EL, Stern J, Hirtz D, Nespeca M, Gidal B, Faught E, French J. Practice guideline update summary: Efficacy and tolerability of the new antiepileptic drugs II: Treatment-resistant epilepsy: Report of the American Epilepsy Society and the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Epilepsy Curr. 2018 Jul-Aug;18(4):269-278. [PMC free article: PMC6145395] [PubMed: 30254528]

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Karceski S. Pregnancy, anti-seizure medications, and seizures. Neurology. 2018 Sep 25;91(13):e1271-e1274. [PubMed: 30249683]

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de Toffol B, Trimble M, Hesdorffer DC, Taylor L, Sachdev P, Clancy M, Adachi N, Bragatti JA, Mula M, Kanemoto K. Pharmacotherapy in patients with epilepsy and psychosis. Epilepsy Behav. 2018 Nov;88:54-60. [PubMed: 30241054]

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Nevitt SJ, Sudell M, Weston J, Tudur Smith C, Marson AG. Antiepileptic drug monotherapy for epilepsy: a network meta-analysis of individual participant data. Cochrane Database Syst Rev. 2017 Dec 15;12:CD011412. [PMC free article: PMC6486134] [PubMed: 29243813]

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Devinsky O, Vezzani A, O'Brien TJ, Jette N, Scheffer IE, de Curtis M, Perucca P. Epilepsy. Nat Rev Dis Primers. 2018 May 03;4:18024. [PubMed: 29722352]

7.

Tian N, Boring M, Kobau R, Zack MM, Croft JB. Active Epilepsy and Seizure Control in Adults - United States, 2013 and 2015. MMWR Morb Mortal Wkly Rep. 2018 Apr 20;67(15):437-442. [PMC free article: PMC6191103] [PubMed: 29672474]

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Dang LT, Silverstein FS. Drug Treatment of Seizures and Epilepsy in Newborns and Children. Pediatr Clin North Am. 2017 Dec;64(6):1291-1308. [PubMed: 29173786]

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O'Dwyer M, Peklar J, Mulryan N, McCallion P, McCarron M, Henman MC. Prevalence and patterns of anti-epileptic medication prescribing in the treatment of epilepsy in older adults with intellectual disabilities. J Intellect Disabil Res. 2018 Mar;62(3):245-261. [PubMed: 29314463]

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Johnson KA, Macfarlane MD, Looi JC. Affective disorders and functional (non-epileptic) seizures in persons with epilepsy. Australas Psychiatry. 2016 Dec;24(6):526-528. [PubMed: 27329644]

11.

DeToledo J. Pregnancy in epilepsy: issues of concern. Int Rev Neurobiol. 2008;83:169-80. [PubMed: 18929081]

12.

Tang MHY, Chong YK, Chan CY, Ching CK, Lai CK, Li YK, Mak TWL. Cluster of acute poisonings associated with an emerging ketamine analogue, 2-oxo-PCE. Forensic Sci Int. 2018 Sep;290:238-243. [PubMed: 30081327]

13.

Suddock JT, Cain MD. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jul 5, 2021. Barbiturate Toxicity. [PubMed: 29763050]

14.

Vidaurre J, Gedela S, Yarosz S. Antiepileptic Drugs and Liver Disease. Pediatr Neurol. 2017 Dec;77:23-36. [PubMed: 29097018]

15.

Giray S, Ozenli Y, Ozisik H, Karaca S, Aslaner U. Health-related quality of life of patients with epilepsy in Turkey. J Clin Neurosci. 2009 Dec;16(12):1582-7. [PubMed: 19837591]

16.

Hamed S, Mohamed K, El-Taher A, Hamed E, Omar H. The sexual and reproductive health in men with generalized epilepsy: a multidisciplinary evaluation. Int J Impot Res. 2006 May-Jun;18(3):287-95. [PubMed: 16254569]

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Sperling MR, Bucurescu G, Kim B. Epilepsy management. Issues in medical and surgical treatment. Postgrad Med. 1997 Jul;102(1):102-4, 109-12, 115-8 passim. [PubMed: 9224482]

Sours: https://www.ncbi.nlm.nih.gov/books/NBK482269/

List of anti-epileptic drugs

Here we list the different AEDs and link to information about what type of seizures they are used for, doses, and possible side effects from either the British National Formulary (BNF), British National Formulary for Children (BNFC), the electronic Medicines Compendium (eMC) or the National Institute for Health and Care Excellence (NICE) clinical guideline for epilepsy (CG137). NICE is an independent organisation that provides national guidance to improve health and social care services in England.

 Click on the links below to search for information about AEDs:

  • by the generic name of the AED
  • by the brand name of the particular type of AED or
  • by the type of seizure or seizures you have.

Generic names with brand names

  • Acetazolamide
  • Brivaracetam available as Briviact
  • Cannabidiol available as Epidyolex 
  • Carbamazepine also available as Tegretol, Tegretol Prolonged Release
  • Clobazam also available as Frisium, Perizam, Tapclob, Zacco
  • Clonazepam
  • Eslicarbazepine acetate available as Zebinix
  • Ethosuximide
  • Everolimus also available as Votubia
  • Fenfluramine available as Fintepla
  • Gabapentin also available as Neurontin
  • Lacosamide available as Vimpat
  • Lamotrigine also available as Lamictal
  • Levetiracetam also available as Desitrend, Keppra
  • Oxcarbazepine also available asTrileptal
  • Perampanel available as Fycompa
  • Phenobarbital
  • Phenytoin also available as Epanutin, Phenytoin Sodium Flynn
  • Piracetam available as Nootropil
  • Pregabalin also available as Alzain, Axalid, Lecaent, Lyrica
  • Primidone also available as Liskantin Saft
  • Rufinamide available as Inovelon
  • Sodium valproate (important information for women here) also available as Epilim,Epilim Chrono,Epilim Chronosphere, Episenta, Epival, Dyzantil
  • Stiripentol also available as Diacomit
  • Tiagabine available as Gabitril
  • Topiramate also available as Topamax
  • Valproic acid available as Convulex, Epilim Chrono, Epilim Chronosphere, Dyzantil
  • Vigabatrin available as Sabril, Kigabeq
  • Zonisamide also available as Zonegran, Desizon

You can find information about which types of seizures different AEDs are used for by following these links to either the NICE guideline, the BNF or, for children the BNFC.

Please note:

  • Valproate: Sodium valproate and Valproic acid must not be used in females of childbearing potential unless the conditions of the Pregnancy Prevention Programme are met and alternative treatments are ineffective or not tolerated. During pregnancy, it must not be used for epilepsy unless it is the only possible treatment.

  • For information on doses and side effects click on the AED name above and this will take you to the electronic Medicines Compendium(eMC), British National Formulary (BNF) or British National Formulary for Children (BNFC)where you can view the patient information leaflet (PIL).

  • A first line AED is an AED that is tried first. Some AEDs added to a first line AED are called second line AEDs.

  • AEDs are not split into first and second line for treating children age 12 and under. 

  • Treatment of neonatal seizures (from birth to 28 days of age) is not covered.

  • ‘Effective’ means the seizures it works for. ‘Monotherapy’ means the AED is taken on its own. ‘Adjunctive' or 'Add-on therapy’ means the AED is taken alongside other AEDs. ‘Tolerance’ means that a drug becomes less effective the longer you take it. A 'tertiary epilepsy specialist' is a speciailst with particular expertise and training in epilepsy. 'idiopathic epilepsy' is where someone's epilepsy is genetic or inherited.

  • Information for this page comes from sources including the British National Formulary (BNF), the British National Formulary for children (BNFC) and the electronic Medicines Compendium (eMC). 

  • Every effort is made to ensure that all information is correct at time of publishing but information may change after publishing. This information is a guide only and is not a substitute for advice from your doctor. Epilepsy Society is not responsible for any actions taken as a result of using this information.

Information updated: August 2021

Medication

The aim of treatment is to stop all of your seizures with the lowest dose of the fewest number of AEDs and with the least side effects.

MedicationFind out more

Seizure types

In March 2017 the International League Against Epilepsy (ILAE), a group of the world's leading epilepsy professionals, introduced a new method to group seizures. This gives doctors a more accurate way to describe a person's seizures, and helps them to prescribe the most appropriate treatments.

Seizure typesFind out more
Sours: https://epilepsysociety.org.uk/about-epilepsy/anti-epileptic-drugs/list-anti-epileptic-drugs
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Treatment - Epilepsy

Treatment can help most people with epilepsy have fewer seizures, or stop having seizures completely.

Treatments include:

  • medicines called anti-epileptic drugs (AEDs)
  • surgery to remove a small part of the brain that's causing the seizures
  • a procedure to put a small electrical device inside the body that can help control seizures
  • a special diet (ketogenic diet) that can help control seizures

Some people need treatment for life. But you might be able to stop if your seizures disappear over time.

You may not need any treatment if you know your seizure triggers and are able to avoid them.

Talk to your specialist about the treatments available and which might be best for you.

Anti-epileptic drugs (AEDs)

AEDs are the most commonly used treatment for epilepsy. They help control seizures in around 7 out of 10 of people.

AEDs work by changing the levels of chemicals in your brain. They do not cure epilepsy, but can stop seizures happening.

Types of AEDs

There are many AEDs.

Common types include:

The best type for you will depend on things like the type of seizures you have, your age and if you're thinking of having a baby.

Some AEDs can harm an unborn baby – see living with epilepsy for more information.

If your doctor recommends taking an AED, ask them about the different types available and which is likely to be the most suitable for you.

Taking AEDs

AEDs are available in a number of different forms, including tablets, capsules, liquids and syrups. You usually need to take the medicine every day.

Your specialist will start you on a low dose and gradually increase it until your seizures stop. If the first medicine you try does not work, your doctor may recommend trying another type.

It's important you follow any advice about when to take AEDs and how much to take. Never suddenly stop taking an AED – doing so could cause a seizure.

If you have not had a seizure for a few years, ask your doctor if you might be able to stop treatment. If they think it's safe, your dose will be reduced gradually over time.

While taking AEDs, do not take any other medicines, including over-the-counter medicines or complementary medicines, without speaking to your GP or specialist. Other medicines could affect how well your AED works.

Side effects

Side effects are common when starting treatment with AEDs. Some may appear soon after starting treatment and pass in a few days or weeks, while others may not appear for a few weeks.

The side effects you may get depend on the medicine you're taking.

Common side effects of AEDs include:

  • drowsiness
  • a lack of energy
  • agitation
  • headaches
  • uncontrollable shaking (tremor)
  • hair loss or unwanted hair growth
  • swollen gums
  • rashes – contact your GP or specialist if you get a rash, as it might mean you're having a serious reaction to your medicine

Contact your GP or specialist if you have symptoms similar to being drunk, such as unsteadiness, poor concentration and being sick. This could mean your dose is too high.

For information about the side effects of your medicine, check the information leaflet that comes with it.

Want to know more?

Brain surgery

Surgery to remove part of your brain may be an option if:

  • AEDs are not controlling your seizures
  • tests show that your seizures are caused by a problem in a small part of your brain that can be removed without causing serious effects

In these cases, there's a good chance that your seizures could stop completely after surgery.

Tests before surgery

If your epilepsy is poorly controlled after trying several AEDs, you may be referred to a specialist epilepsy centre to see if surgery might be possible.

This will usually involve having several tests, such as:

  • brain scans
  • an electroencephalogram (EEG) – a test of your brain's electrical activity
  • tests of your memory, learning abilities and mental health

The results of these tests will help you and your specialist decide if surgery is an option for you, and what the result of surgery might be.

What happens during surgery

Surgery for epilepsy is usually carried out under general anaesthetic, where you're asleep.

The surgeon makes a small cut in your scalp and creates an opening in your skull so they can remove the affected part of the brain.

The openings in your skull and scalp are closed at the end of the operation.

Recovery and risks

It's likely to take a few weeks or months for you to feel back to normal after surgery.

Your seizures may not stop straight away, so you might need to keep taking AEDs for 1 to 2 years.

There's a risk of complications from surgery, such as problems with your memory, mood or vision. These problems may improve over time, or they may be permanent.

Before having surgery, make sure you talk to your surgeon about the possible risks.

Further information

Other procedures

If AEDs are not controlling your seizures and brain surgery is not suitable for you, there are other procedures that could help.

Vagus nerve stimulation (VNS)

Vagus nerve stimulation (VNS) is where a small electrical device similar to a pacemaker is placed under the skin of your chest.

The device is attached to a wire that goes under your skin and connects to a nerve in your neck called the vagus nerve. Bursts of electricity are sent along the wire to the nerve.

It's thought this can help control seizures by changing the electrical signals in the brain.

VNS does not usually stop seizures completely, but it can help make them less severe and less frequent. You'll probably still need to take AEDs.

Side effects of VNS include a hoarse voice, a sore throat and a cough when the device is activated. This normally happens every 5 minutes and lasts for 30 seconds.

The battery for the VNS device typically lasts up to 10 years, after which time another procedure will be needed to replace it.

Deep brain stimulation (DBS)

Deep brain stimulation (DBS) is similar to VNS. But the device placed in the chest is connected to wires that run directly into the brain.

Bursts of electricity sent along these wires can help prevent seizures by changing the electrical signals in the brain.

DBS is a fairly new procedure that's not used very often, so it's not yet clear how effective it is for epilepsy.

There are also some serious risks associated with it, including bleeding on the brain, depression and memory problems.

If your doctor suggests DBS as an option, make sure you talk to them about the potential benefits and risks.

Further information

Ketogenic diet

A ketogenic diet is a diet high in fats, and low in carbohydrates and protein. In children, the diet is thought to make seizures less likely by changing the levels of chemicals in the brain.

The ketogenic diet was one of the main treatments for epilepsy before AEDs were available. But it's now not widely used in adults because a high-fat diet is linked to serious health conditions, such as diabetes and cardiovascular disease.

A ketogenic diet is sometimes recommended for children with seizures that are not controlled by AEDs. This is because it's been shown to reduce the number of seizures in some children.

It should only be used under the supervision of an epilepsy specialist with the help of a dietitian.

Further information

Complementary therapies

There are several complementary therapies that some people with epilepsy feel work for them. But none has been shown to reduce seizures conclusively in medical studies.

You should therefore be cautious about advice from anyone other than a GP or specialist to reduce or stop taking your medicine and try alternative treatments. Stopping your medicine without medical supervision may cause seizures.

Herbal remedies should also be used cautiously because some of their ingredients can interact with epilepsy medicine.

St John's Wort, a herbal remedy used for mild depression, is not recommended for people with epilepsy because it can affect the levels of epilepsy medicine in the blood and may stop the medicine working properly.

There are reports that some strong-smelling aromatherapy treatments, such as hyssop, rosemary and sweet fennel, may trigger seizures in some people.

For some people with epilepsy, stress can trigger seizures. Stress-relieving and relaxation therapies such as exercise, yoga and meditation may help.

Further information

Page last reviewed: 18 September 2020
Next review due: 18 September 2023

Sours: https://www.nhs.uk/conditions/epilepsy/treatment/
Pharmacology - Seizures (Epilepsy) drugs for nursing RN PN NCLEX

Warning: Anticonvulsant medication may affect the levels of vitamins B2, B6, B22, C, D, E, beta-carotene, biotin and folate.

Medications may have different marketing names in Canada than in the United States.

Available in Canada by prescription

Generic Name
Trade Name
Additional Names/Information

Acetazolamide

Acetazolam

Carbamazepine
Tegretol
Mazepine, Carbamazepine CR

Clobazam
Frisium

Clonazepam
Rivotril
Clonpam, Clonazepam-R

Diazepam
Valium
Diastat, Diazemuls, Dipam

Ethosuximide
Zarontin

Fosphenytoin
Cerebyx

Gabapentin
Neurontin

Lacosamide
Vimpat

Lamotrigine
Lamictal
This drug is not approved in Canada for persons under 16 years of age except in the treatment of Lennox-Gastaut syndrome. Please see Health Canada`s safety update (2004).

Levetiracetam
Keppra

Lorazepam
Ativan
Loraz

Methsuximide
Celontin
This drug has been discontinued in Canada. 2015-06-05

Nitrazepam
Mogadon
Nitrazedon

Oxcarbazepine
Trileptal
Please see Health Canada’s safety update (2005).

Paraldehyde

This drug is not generally used as an anticonvulsant medication except in hospital (injected rectally or intramuscularly) to stop status epilepticus.

Phenobarbital

Phenobarb, Phenobarbital Sodium

Phenytoin
Dilantin
Phenytoin Sodium, Tremytoine

Pregabalin
Lyrica

Primidone

Rufinamide
Banzel

Stiripentol
Diacomit

Topiramate
Topamax

Valproic Acid
Epival, Depakene
Divalproex Sodium, Sodium Valproate

Vigabatrin
Sabril

Available in the United States

Felbamate (Felbatol)

Tiagabine Hydrochloride (Gabitril)

Zonisamide (Zonegran)

For more information on any of the listed drugs, you can:

Click here to learn more about medication.

Sours: https://epilepsyontario.org/about-epilepsy/treatments/medications/anticonvulsantanti-seizure-medication-from-a-to-z/

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