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Ezogabine Considerations:
Consider risk factors for urinary retention. Adjust dose for renal and hepatic dysfunction.
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Felbamate Primary Mechanism:
Blocks NMDA site on glutamate rcptr, inhibition of Na+/Ca++ channels
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Felbamate FDA approved Indications:
Partial (adjunct, refractory)
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Felbamate Adverse effects:
- Common: GI
- Rare: aplastic anemia (1:3000), liver failure (1:10,000)
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Felbamate Monitoring:
CBC, LFT’s
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Felbamate Inducer/Inhibitor:
Inhibitor
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Felbamate Considerations:
Use only for refractory seizures due to side-effect profile.
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Gabapentin Primary Mechanism:
Modulates Ca++ influx by hyper-excited neurons
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Gabapentin FDA approved Indications:
Partial (adjunct)
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Gabapentin Adverse effects:
Common: CNS, fatigue, weight gain, tremor, N/V
-
Gabapentin Monitoring:
SCr
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Gabapentin Inducer/Inhibitor:
None
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Gabapentin Considerations:
Need tid dosing due to saturable mechanism of absorption. Adjust for renal dysfunction.
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What is the goal of treatment?
Decrease frequency
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What is the #1 reason for treatment failure?
Non-adherence
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What are the criteria that must be met when considering a trial drug taper?
- Seizure > or = 2 years
- Normal neurological exam/IQ
- EEG normalized on medication
- Seizures were under control within 1 year of first episode (Resistant seizure, not recommended for removal of drug)
- Age of onset between 2 and 35 years
- One type of seizure
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What drugs are indicated as monotherapy (not adjunct) for Epilepsy?
- Oxcarbazapine
- Phenobarbitol-Primidone
- Topirimate
- Valproic Acid
- Carbamazapine
- Ethosuximide
- Lacosamide
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When checking phenytoin levels, what lab will give you the most accurate information?
Free drug
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What are the laboratory thresholds for Phenytoin?
Corrected phenytoin needs to be calculated if total phenytoin is measured and the patient has albumin <4.4 g/dL, or severe renal dysfunction (CrCl<24)
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What is the therapeutic range for Phenytoin?
10-20mcg/ml, free 0.5-3mcg/ml
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What side-effects are associated with chronic phenytoin therapy?
- Gingival hyperplasia
- Vitamin D deficiency – bone softening (Ricketts- kids or osteomalacia- adults)
- Folic acid deficiency
- Peripheral neuropathy
- Hirsutism – hair growth
- Coarsening of facial features- masculinization
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Lacosamide Primary Mechanism:
Enhances slow inactivation of Na+ channels
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Lacosamide FDA approved Indications:
Partial
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Lacosamide Adverse effects:
- Common: CNS
- Rare: asymptomatic AV block
-
Lacosamide Monitoring:
Baseline ECG in those at risk
-
Lacosamide Inducer/Inhibitor:
None
-
Lacosamide Considerations:
Not for severe liver dx. IV does not have to be diluted.
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Lamotrigine Primary Mechanism:
Inhibition of Na+ channels
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Lamotrigine FDA approved Indications:
Partial (“switch” therapy), 1º Generalized Tonic-clonic (adjunct)
-
Lamotrigine Adverse effects:
- Common: CNS, diplopia, headache
- Rare: SJS, TEN (1:1000 adults, 1:100 children), aseptic meningitis
-
Lamotrigine Monitoring:
CBC, LFT’s
-
Lamotrigine Inducer/Inhibitor:
None
-
Lamotrigine Considerations:
Incidence of life-threatening side effects higher with valproic acid use. Approved for monotherapy if >16yo.
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