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Informatics in Pharmacy

Seizures: Epilepsy

August 13, 2018 By Dr. G, PharmD

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*See the seizure medication table  for quick reference.
*Seizure Emergencies

Epilepsy Treatment Options:

Know doses for narrow therapeutic index drugs like phenytoin, but mostly need to know what kind of seizure and major side effects that would cause you to choose a different therapy. Also know REMS programs.

  • Benzos can be used as adjunctive, short-term therapy (clorazepate, clonazepam, diazepam or lorazepam)
  • Brivaracetam
  • Carbamazepine – Beware of Stevens Johnsons syndrome with carbamazepine, induced its own metabolism, pharmacogenomic considerations (HLA-B testing in Asians), blood disorders
  • Eslicarbazepine
  • Ethosuximide – Absence seizures
  • Felbamate in severe, refractory seizures.  Severe side effects: aplastic anemia, liver damage.  Adjunct for Lennox-Gestault
  • Fosphenytoin
  • Gabapentin – Also for peripheral neuropathy
  • Lacosamide – partial onset seizure, increases suicidal ideation
  • Lamotrigine – Adjunct for partial, bipolar, Lennox-Gestault. Valproate inhibits the metabolism (must lower dose).  Carbamazepine induces metabolism.  Titrate to avoid Stephen-Johnson’s syndrome.  Estrogen induces metabolism (increase dose).  Good for patients with sexual dysfunction
  • Levetiracetam – partial and myoclonic, traumatic brain injury, adjust in renal dysfunction
  • Oxcarbazepine – no auto-induction, partial, bipolar, causes hyponatremia, some cross sensitivity with carbamazepine. Good for sexual dysfunction.
  • Perampanel – neuropsychiatric effects
  • Phenobarbital – partial and generalized, not for absence seizures, used for anxiety too.
  • Phenytoin – Dose-related effects include nystagmus, ataxia, drowsiness, cognitive impairment. Non-dose related effects include gingival hyperplasia, hirsutism, acne, rash, hepatotoxicity, coarsening of facial features. Therapeutic range: 10-20 mg/ml.   Michaelis–Menten saturable kinetics, so dose accordingly.
    • Dose titration:
    • < 7 mg – increase 100 mg daily
    • 7-12 increase 50 mg daily
    • > 12 increase by 30 mg or less
  • Pregabalin: reduce dose in renal dysfunction
  • Valproate: good for absence seizures, migraine and partial complex seizures.  Causes neural tube defects, beware in women of childbearing age.  Can increase anemia.
  • Primidone: Metabolized to phenobarbital.  Also used for tremor.
  • Tigabin: Use as an adjunct in partial seizures, may cause seizures
  • Topiramate: Adjunct for partial seizures or Lennox-Gestault. Warning in open-angle glaucoma.
  • Vigabatin: SHARE Rems program.  Causes retinal dysfunction.
  • Zonisamide: Avoid in sulfa allergy, decreases the ability to sweat, increases kidney stones.

*******No Valproic Acid in potentially pregnant patients***********

Also avoid: phenytoin, carbamazepine, and phenobarbital, but not as severely.  Try to use a single agent.

May DC epilepsy meds if:

  1. Seizure free for at least 2 years on medication
  2. Single type of partial or primary seizure
  3. Normal neurological exam and normal IQ
  4. EGG normal

Drugs that can induce seizures: tramadol, FQs, bupropion, imipenem/cilastatin, benzo withdrawal

Electrolytes that can induce seizures: hyponatremia, hypernatremia, hypercalcemia.

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acid base acidosis acute coronary syndrome alkalosis analgesics anaphylaxis aortic dissection arrhythmia Beta-Blockers biostatistics blood pressure cardiac markers CHA2DS2-VasC cocaine COVID-19 diabetes diabetes inspidius Guidelines heart failure Heparin hypersensitivity hypertension hypovolemic shock intubation ionotropes journal club lipids LMWH medication safety morphine conversions myocardial infarction needs work NOAC NSTEMI obstructive shock pharmacoeconomics pheochromocytoma pressors reference materials right mi sedation septic shock shock STEMI Updated 2020