Post on 22-Dec-2015
Anti Epileptic Drugs (AEDs)
Sampath Charya, MD, FAAN, FAASM
VAMC, Fayetteville, NC
AEDs…
Disclosures
None
AEDs
Objective
After completion of this activity, participants will be able to review:
Mechanisms of AEDs Older AEDs Newer AEDs AED choices by seizure types
AEDs…
Seizure (SZ) VS Epilepsy
Acute treatment
Chronic treatment
Prevention
AEDs…
SZ precautions
Education of patient and family
AED use
Conditions that may be mistaken for epilepsy
Syncope
Transient ischemic attacks (TIAs)
Transient global amnesia
Migraines
AEDs…
Conditions that may be mistaken for epilepsy
Drop attacks
Panic attacks, hyper ventilation
Non epileptic events (Pseudo seizures)
Hallucinations and delusions
Conditions that may be mistaken for epilepsy
Cataplexy
Elevated intra cranial pressure
Hyperkplexia
Hypersomnia/Microsleeps
AEDs…
Conditions that may be mistaken for epilepsy
Metabolic (Example: Hypoglycemia)
Neurological conditions:
Dyskinesia, Tremors, Involuntary movements
AEDs…
Conditions that may be mistaken for epilepsy
Cardiac dysrhythmias
Vestibular disorders
Psychosis
Parasomnias, sleep movements
AEDs…
Quick review of seizures
Seizure types:
Partial/focal
Simple
Complex
Generalized
AEDs…
Seizure types:
Atonic
Myoclonus
Mixed
Epilepsy syndromes
AEDs…
Seizure types:
Transient and provoked
Non-epileptic
AEDs…
Electroencephalogram (EEG)
References/Sources:
Spehlmann’sSecond edition EEG PrimerBruce J. FischElseviere
AEDs…
EEG
AEDs…
EEG
AEDs…
EEG
AEDs…
EEG
AEDs
Older generation AEDs:
Phenobarbital
Phenytoin
Ethosuximide
Carbamazepine
AEDs…
Older generation AEDs:
Valproic acid
Clonazepam
Lorazepam
Diazepam
Piracetam
AED…
Newer AEDs:
Leviteracetam
Lamotrigine
Topiramate
Zonisamide
AEDs…
Newer AEDs:
Lacosamide
Perampanel
Clobazam
Oxcarbazepine
AEDs…
Newer AEDs:
Gabapentin
Pregabalin
Rufinamide (Lennox Gastaut SX)
AEDs…
Possible mechanisms of action of AEDs
Sodium channel (Phenytoin, Carbamazepine, Lacosamide, Rufinamide, Topiramate, Lamotrigine…)
Potassium channel (Ezogabin)
Calcium channel (Ethosuximide, Clobazam, Zonisamide, Topiramate, Pregabalin…)
NMDA receptor (Perampanel)
AEDs…
Possible mechanisms of action of AEDs
Inhibitory (Phenobarbital, Benzodiazepines, Gabapentin, Topiramate, Zonisamide, Valproate, Felbamate, Tiagabin, Vigabatrin, …)
Multiple (Topiramate, Felbamate, Leviteracetam, Valproate…)
AEDs…
Sodium channel drugs:
Phenytoin
Carbamazepine
Phenobarbital
Lamotrigine
AEDs…
Inhibitory:
Lorazepam
Diazepam
Gabapentin
Pregabalin
AEDs…
Inhibitory:
Vigabatrin (Infantile spasms, focal SZ…)
Tiagabin (Adjunct for focal SZ)
AEDs…
Inhibitory:
Phenobarbital
Clobazam (Infantile spasms)
Midazolam
AEDs…
Excitatory:
Perampanel
Some of the newer agents
AEDs…
Ketogenic diet
Multiple effects
Exact mechanism not fully known
AEDs…
Seizure treatment
AEDs…
Seizure treatment
Identify the need to treat
Treat the underlying cause
Identify the seizure type, localization
Choice of AEDs
Follow-up
AEDs…
Seizure treatment
Common side effects of AEDs:
Dizziness (several)
Nausea (Several)
Sedation (Phenobarbital, gabapentin, Carbamazepine, Valproic acid, Phenytoin, Topiramate, Benzodiazepines…)
Mood changes (Leviteracetam, Gabapentin, Topiramate, Carbamazepine, Benzodiazepines, Valproic acid, lamotrigine…)
AEDs…
Side effects of AEDs
Allergy, sensitivity, and Rash (Several)
Steven Johnson syndrome (Lamotrigine, especially on valproate, Carbamazepine, Phenytoin HLA-1502, Asians)
Headache (several)
Insomnia (lamotrigine)
Leukopenia (Carbamazepine, Phenytoin, Phenobarbital, Felbamate…)
Ataxia (several)
Systemic effects (several)
AEDs…
Side effects of AEDs
Abnormal liver function tests (Almost most AEDs)
Effects on concomitant meds (Older meds)
CNS effects (phenobarbital, Carbamazepine, Valproic acid, Topiramate, Lamotrigine…)
Cardiac effects (Phenytoin)
Other GI effects (Several)
AEDs…
Side effects of AEDs
Effects on oral contraceptives (Older meds)
Ophthalmologic (Topiramate, Zonisamide…)
Renal (Gabapentin, Leviteracetam…)
Reproductive system (Several)
Body weight (Topiramate, Zonisamide, gabapentin, Valproic acid, Carbamazepine…)
AEDs…
Seizure treatment
Tolerability
Compliance
Motivation
Socio-economic issues
Epilepsy clinical course
AEDs…
References and suggested readings
Chadwick, D &Turnbull, D. M. (1985)Neurology Neurosurgery Psychiatry , 48 173-7
Barron, T. F. & Hunt, S. L. (1997) Review of the newer antiepileptic drugs and the ketogenic diet. Clin pediatr phila, 36, 513-21
Marson, A. G., Kadir, Z. A., Hutton, J. L. & Chadwick, D. W. (1997) The new antiepileptic drugs: a systematic review of their efficacy and tolerability Epilepsia, 38, 859-80
Handbook of Epilepsy Treatment , Simon Shorvon (ISBN: 0-632-05708-4)
Thanks!