Antiepileptics

Notes

For further information on the management of epilepsy and choice of antiepileptic drug therapy refer to:

  • SIGN guideline ‘Diagnosis and Management of Epilepsy in Adults’ (www.sign.ac.uk)
  • NICE CG137 guidance on the epilepsies (www.nice.org.uk)
  • ‘Consensus guidelines into the management of epilepsy in adults with an intellectual disability’.
Note: The effectiveness of hormonal contraceptives may be considerably reduced by some antiepileptics; consider this when discussing choice of contraception. Refer to SIGN guidance and to Contraceptives for further information. Women wishing to become pregnant and those who conceive should be counselled by a specialist about possible risks and changes in antiepileptic medication.

 

MHRA: Brand switching of antiepileptics for seizure control (www.mhra.gov.uk):

  • Carbamazepine, phenobarbital, phenytoin, primidone: all use should be brand or manufacturer-specific.
  • Valproate, lamotrigine, perampanel, clobazam, clonazepam, oxcarbazepine, eslicarbazepine, zonisamide, topiramate: for most patients, switching between brands or manufacturers of these medicines should not pose a significant risk. However, any patient who has experienced loss of effect or adverse effects on switching brands of one of these medicines should be managed using specific medicine brand or manufacturer.
  • Levetiracetam, lacosamide, tiagabine, gabapentin, pregabalin, ethosuximide: may be prescribed, supplied and administered generically unless there are specific circumstances dictating otherwise.

• In addition to the 3 risk-based categories of antiepileptic drugs, patient-related factors should be considered when deciding whether it is necessary to maintain continuity of supply for a specific product (www.gov.uk).

For indications other than seizure control (eg trigeminal neuralgia) all antiepileptics may be used generically.

Choice of antiepileptic drug monotherapy (from SIGN Guideline 143)

Partial and secondary generalised seizures Primary generalised seizures Uncertain seizure type
• carbamazepine
• sodium valproate
• lamotrigine
• oxcarbazepine
• levetiracetam
• lamotrigine
• levetiracetam
• sodium valproate
As recommended by specialist
• Side-effect and interaction profiles should direct the choice of drug for the individual patient. Refer to the BNF for the wide range of interactions with this group of drugs.
• It is acceptable to titrate up the antepileptic drug dose more slowly in certain patient groups, eg older people, patients with learning disabilities.
• Some antiepileptic drugs can exacerbate myoclonus, notably gabapentin, carbamazepine, oxcarbazepine and tiagabine.

 

Read More