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!