1. Anti Epileptic Drugs (AEDs) Sampath Charya, MD, FAAN, FAASM VAMC, Fayetteville, NC

2. AEDs… Disclosures  None

3. 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

4. AEDs… Seizure (SZ) VS Epilepsy Acute treatment Chronic treatment Prevention

5. AEDs… SZ precautions Education of patient and family AED use

6. Conditions that may be mistaken for epilepsy  Syncope  Transient ischemic attacks (TIAs)  Transient global amnesia  Migraines

7. AEDs… Conditions that may be mistaken for epilepsy  Drop attacks  Panic attacks, hyper ventilation  Non epileptic events (Pseudo seizures)  Hallucinations and delusions

8. Conditions that may be mistaken for epilepsy  Cataplexy  Elevated intra cranial pressure  Hyperkplexia  Hypersomnia/Microsleeps

9. AEDs… Conditions that may be mistaken for epilepsy  Metabolic (Example: Hypoglycemia)  Neurological conditions:  Dyskinesia,  Tremors,  Involuntary movements

10. AEDs… Conditions that may be mistaken for epilepsy  Cardiac dysrhythmias  Vestibular disorders  Psychosis  Parasomnias, sleep movements

11. AEDs… Quick review of seizures  Seizure types:  Partial/focal  Simple  Complex  Generalized

12. AEDs… Seizure types: Atonic Myoclonus Mixed Epilepsy syndromes

13. AEDs… Seizure types:  Transient and provoked  Non-epileptic

14. AEDs… Electroencephalogram (EEG) References/Sources: Spehlmann’s Second edition EEG Primer Bruce J. Fisch Elseviere

15. AEDs… EEG

16. AEDs…

17. AEDs…

18. AEDs…

19. AEDs Older generation AEDs: Phenobarbital Phenytoin Ethosuximide Carbamazepine

20. AEDs… Older generation AEDs: Valproic acid Clonazepam Lorazepam Diazepam Piracetam

21. AED… Newer AEDs: Leviteracetam Lamotrigine Topiramate Zonisamide

22. AEDs… Newer AEDs: Lacosamide Perampanel Clobazam Oxcarbazepine

23. AEDs… Newer AEDs: Gabapentin Pregabalin Rufinamide (Lennox Gastaut SX)

25. 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)

26. AEDs… Possible mechanisms of action of AEDs Inhibitory (Phenobarbital, Benzodiazepines, Gabapentin, Topiramate, Zonisamide, Valproate, Felbamate, Tiagabin, Vigabatrin, …) Multiple (Topiramate, Felbamate, Leviteracetam, Valproate…)

27. AEDs… Sodium channel drugs:  Phenytoin  Carbamazepine  Phenobarbital  Lamotrigine

28. AEDs… Inhibitory: Lorazepam Diazepam Gabapentin Pregabalin

29. AEDs… Inhibitory: Vigabatrin (Infantile spasms, focal SZ…) Tiagabin (Adjunct for focal SZ)

30. AEDs… Inhibitory: Phenobarbital Clobazam (Infantile spasms) Midazolam

31. AEDs… Excitatory:  Perampanel  Some of the newer agents

32. AEDs… Ketogenic diet  Multiple effects  Exact mechanism not fully known

33. AEDs… Seizure treatment

34. AEDs…  Identify the need to treat  Treat the underlying cause  Identify the seizure type, localization  Choice of AEDs  Follow-up

35. 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…)

36. 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)

37. 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)

38. 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…)

39. AEDs… Seizure treatment  Tolerability  Compliance  Motivation  Socio-economic issues  Epilepsy clinical course

40. 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)

41. Thanks!