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’s Second edition EEG Primer Bruce J. Fisch Elseviere

AEDs… EEG

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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…  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,  Barron, T. F. & Hunt, S. L. (1997) Review of the newer antiepileptic drugs and the ketogenic diet. Clin pediatr phila, 36,  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,  Handbook of Epilepsy Treatment, Simon Shorvon (ISBN: )

Thanks!