This guide is dedicated to helping provide an intentional approach to thinking about the different anti-epileptic medications. There are a many different medications available, and each has its own set of advantages and disadvantages. The sections below will help in picking the right anti-epileptic for a patient who is just beginning therapy.
WHAT ARE THE MEDICATIONS WE HAVE AVAILABLE TO US?
There are many different medications, but they fall into the general categories below:
- Focal seizure medications: Carbamazepine, Oxcarbazepine, Lacosamid
- Generalized seizure/broad spectrum medications: Levetiracetam, Lamotrigine, Topiramate, Valproic Acid, Zonisamide
- Other: Pregabalin, Gabapentin
CHARACTERIZING THE EPILEPTIC PATIENT
It is not fair to reduce a patient to a list of characteristics, however for the sake of developing a framework for prescribing anti-epileptic medications, it is advantageous to keep in mind some of the most relevant aspects of a patient. It is not practical to list EVERY aspect here, however some of the major categories are outlined. These will become a bit more obvious as we discuss specific medications.
What type of epilepsy does the patient have?
Understanding the difference between focal and generalized seizures is an important first step. It is advantageous to tailor therapy to the exact etiology of the condition.
How compliant is the patient with medical care?
Compliance can be multifactorial (willingness, financial status, access to care, etc). The bottom line is that some medications require very careful monitoring, and may not be the practical option for some patients.
Does the patient have contraindications to using any medications?
Current/planned pregnancy, mood disorders, liver disease, and many other factors must be considered given the side effect profiles of antiepileptic medications.
Does the patient have other conditions that certain antiepileptics can provide benefit for?
Antiepileptics are used in many different contexts, and the therapeutic potential of certain medications can be used to maximize the benefit in patients. Those who have seizures and another condition (mood disorders, headache, etc) may have both of their conditions treated with one medication!
PATIENTS WITH FOCAL SEIZURES
In patients who have focal seizures, their are specific medications that are thought to work better then the broad spectrum antiepileptics. It is important to realize that the medcaitoins for generalized epilepsy can still be very effective for patients with focal seizures, but it is worth considering the medications below first.
Patients who are medically compliant
Carbamazepine is very much worth considering an ideal setting (without any other variables) patients with focal seizures are thought to get the most benefit from carbamazepine. It is an effective medication that also can have a positive impact on mood (it is used to treat bipolar disorder) With that in mind, this medication requires close monitoring of various lab values (CBC, LFT, and serum concentrations of the medication) making it less practical for some patients. If the patient in question will not be able to come regularly for close monitoring on this medication, it may be an unsafe option.
Patients who are not medically compliant
Patients who can not be followed closely clinically may be best managed with the medications listed in the section below.
PATIENTS WHO ARE NOT CANDIDATES FOR FOCAL SEIZURE MEDICATIONS
In some settings focal seizure medications are not practical options. Most obviously are patients who have generalized seizures (that can be made WORSE by certain focal seizure medications), however even some focal seizure patients may be best managed with broad spectrum antiepileptics. Here is how to navigate this class of medications intelligently.
Patients who are not at risk for/have no pasty history of mood disorders
Levetiracetam is a very effective medication that has a very mild side effect profile (and does not require really any monitoring by the physician in terms of routine labs/serum concentrations). Its largest drawback is that it can negatively impact the mood of patients and may increase the risk of suicide. In patients who are not high risk for mood disorders/suicide, this medication really should be one of the first ones considered. Carbamazepine is thought to be more effective for patients with focal seizures, however patients who are not good candidates for carbamazepine can be treated very effectively with levetiracetam.
Patients who would benefit from mood disorder treatment
Lamotrigine is another effective broad spectrum antiepileptic that has a very mild side effect profile. It also is has the advantage of elevating the mood of many patients, as it is used to treat bipolar disorder as well. Its major drawback is that it can cause Steven-Johnson syndrome, and must be titrated very carefully in patients. This long titration period may not necessarily be practical for every patient.
Patients who suffer from migraines/headaches
Topiramate can be a good medication to consider in patients who also suffer from migraine headaches. It can be possible to manage both the epilepsy and migraines with this medication. It is important to note that this medication can cause kidney stones to form in the body, and to prevent this, requires that the patient drink plenty of water.
Page Updated: 07.27.2016