choice of antiepileptic drug
DESCRIPTION
CHOICE OF ANTIEPILEPTIC DRUG. Magnitude of the problem. Epilepsy affects: approximately 1 in 50 children and 1 in 100 adults. PHARMACOTHERAPY OF EPILEPSY: The issues. Is treatment justified? When to start treatment? How to start drug treatment? Which AED? Which dosage? - PowerPoint PPT PresentationTRANSCRIPT
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Magnitude of the problem
Epilepsy affects: approximately 1 in 50 children
and 1 in 100 adults.
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PHARMACOTHERAPY OF EPILEPSY: The issues
Is treatment justified? When to start treatment? How to start drug treatment? Which AED? Which dosage? When should AED combinations be
used? Risks associated AED treatment? How long should treatment be
continued?
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PHARMACOTHERAPY OF EPILEPSY:
The issues Is treatment justified? When to start treatment? How to start drug treatment? Which AED? Which dosage? When should AED combinations be
used? How long should treatment be
continued?
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1840 1860 1880 1900 1920 1940 1960 1980 2000
0
5
10
15
20
BromidePhenobarbital
Phenytoin Primidone
Ethosuximide
Sodium valproate
Benzodiazepines
Carbamazepine
Vigabatrin
ZonisamideLamotrigine
FelbamateGabapentin
Topiramate Fosphenytoin
OxcarbazepineTiagabine
Levetiracetam
More
Year
AEDs
Antiepileptic drug Antiepileptic drug developmentdevelopment
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Major considerations in choosing an AED
Type of seizure
Type of epileptic syndrome
Adverse effect profile
Age & gender
Ease of use (fast and easy dose titration)
Specific co-morbidities
Cost
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Best first AED
Not a “ one size fits all” scenario Choice of drug:
Depends on : Efficacy Tolerability affordability
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Best first AED
Efficacy:Determined by the type of seizure / epileptic syndrome
Step.1:To diagnose epileptic syndrome
Step 2. If not possible, try to exclude JME or absences
Carbamzepine & phenytoin will aggravate JME CBZ, phenytoin, tiagabine & vigabatrin will aggravate
Absences Step.3;
Valproate, lamotrigine or topiramate, Levitiracetum
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Epileptic syndrome
The clinical event Ictal & interictal EEG characteristics Age of onset Characteristic evolution &
progression. Presence or absence of family history
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Why should we identify the epileptic syndrome?
Whether to investigate the patient further or not
Which drug to choose for the control of seizure
To predict prognosis
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Drugs of choice in certain epileptric syndromesEpilepsy syndrome Drugs of choiceFebrile seizure Rectal diazepam
West’s syndrome ACTH, Vigabatrin
Lennox-Gestaut Valproate, lamotrigine, topiramate, clobazam
BECTS Carbamazepine, Valproate
Early onset Benign Occipital seizures
Intermittent rectal diazepam
Late onset childhood occipital seizure
carbamazepine
Absence epilepsy Valproate, Ethosuximide, lamotrigine
Juvenile myoclonic epilepsy Valproate, Lamotrigine
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Best first AED
Efficacy: Step.2:If not possible, try to exclude JME or absences Carbamazepine & phenytoin will aggravate JME
CBZ, phenytoin, tiagabine & vigabatrin will aggravate Absences
Step.3; If the seziure can not be typed
Valproate, lamotrigine or topiramate, Levitiracetum
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Best first AED
Efficacy:
Step.3: If not possible, find out the type the seizure
Partial seizure / primary generalized seizure
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Choice of AED
Partial / GTC Seizure Carbamazepine, phenytoin, valproic acid
(sodium valproate ), phenobarbital and primidone are all effective CBZ –drug of choice
All forms of generalised seizure: Valproate; drug of choice
Absence seizures: Valproate, Ethosuximide
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Best first AED
Differentiation of partial Versus Generalised epilepsy is not always possible in infants
Eg: Dravet’s syndrome ( severe myoclonic epilespy of chiildhood) usually presents with hemiconvulsion.
Infantile spasm: Pattern can change from generalised to partial
seizures
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Best first AED
Efficacy:
If the seizure can not be typed
Valproate, lamotrigine or topiramate, Levitiracetum
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Best first AED
Tolerability: Valproate & Carbamazepine are better
toleratedthan Pheno or phenytoin
Affordability; Newer AEDs are costly compared older
ones
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Newer AEDS
What is real advantage of these newer drugs?
Are they going to replace older drugs? Does high cost of these drugs justify
its usefulness? What are the situations where we can
use these drugs?
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Newer drugs
No major differences in efficacy between drugs
Major differences in side effects profiles
Drug interaction potential also differs
Drug choice should be tailored to the patient
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EFFICAY OF NEWER AED AS MONOTHERAPY RCT have shown no major difference in
seizure control between: LTG vs CBZ * LTG better tolerated LTG vs DPH * LTG better tolerated OXC vs CBZ * CBZ increased allergy OXC vs VPA * No difference OXC vs DPH * withdrawal more in DPH GBP vs CBZ * Withdrawal more in GBP GBP vs LTG TPM vs CBZ & VPA * No difference
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UK NICE guidelines for the use of new AED
If established drugs have failed Typically carbamazepine or valproate
If most appropriate older drug is contraindicated
If older drugs could interact with other medications
If older drugs are already known to be poorly tolerated by the patient
If patient is a woman of child bearing potential
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Newer AEDs in Epilepsy Management
Among the newer AEDs, is there a preference of any particular AED for a specific type of seizure?
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Broad spectrum AED
Lamotrigine Topiramate Levitiracetum Clobazam
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Newer AED for generalised seizure
Lamotrigine, Topiramate,
Zonisamide, and Levetiracetam
Oxcarbazepine, tiagabine and gabapentine are ineffective
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AED for JME
Valproate is superior
Second choice
Levitiracetum Clobazam Topiramate Lamotrigine
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JME
When on lamotrigine: If tonic-clonic seizures have been
controlled, but myoclonic seziures persist
Add clonezepam , before changing to valproate, topiramate or levetiracetam
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Newer AED for Partial seizure
Lamotrigine, Oxcarbazepine, Clobazam Gabapentin and Topiramate is same as that of carbamazepine or
phenytoin.
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NEWER AED FOR PARTIAL SEIZURE AAN guideline recommendations for
new onset partial seizure Gabapentin Topiramate Oxcarbamazepine Lamotrigine
However, levitiracetum, zonisamide & tiagabine are also effective
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Drugs effective for both generalized & partial;
Valproate, LTG, Topiramate, Levetiracetum and Zonisamide.
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Efficacy Spectrum of Available AEDsAbsences & certain myoclonic seizures
Broad spectrum
Partial & generalised
Partial seizures Absence only
Valproic acid
Ethosuximide
Sodium valproate
Lamotrigine* *
Carbamazepine
Phenytoin*
Ethosuximide
Topiramate Oxcarbazepine*
Levitiracetam Vigabatrin*
Zonisamide Gabapentin*
Tiagabine** May exacerbate myoclonic and absence seizures Vigabatrin is also effective in infantile spasms * * Lamotrigine may aggravate severe myoclonic epilepsy
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TOLERABILTY OF NEW AEDS
Gabapentin Levetiracetum Lamotrigine
Oxcarbamazepine Tiagabine Topiramate Vigabatrin
Well tolerated
Higher treatment withdrawal
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EFFECT ON COGNITION
Levetiracetum Lamotrigine Tiagabine
No significant effect on Cognition,
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How long the AED will take to produce its effect?
Time to achieve steady state
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Time to achieve steady stateof AEDsDRUG HALF LIFE TIME TO ACHIEVE
STEADY STATE
Phenytoin 15-30 hrs 5-15 days
Carbamazepine 11-17 hrs 3-5 days
Valproate 6-18 hrs 2-4 days
Oxcarbamazepine 8-10 hrs 3-4 days
Lamotrigine 10-15 hrs 5-15 days
Topiramate 20-24 hrs 5 days
Levetiracetum 7-8 hrs 2-3 days
Gabapentin 5-7 days 1-2 days
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Inappropriate AED choice and
seizure worsening
Wrong selection of drugs can worsen seizure
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AEDs which may aggravate some epileptic syndromes
Drug Syndrome
Carbamazepine Absence epilepsy Juvenile myoclonic epilepsyProgressive Myoclonus E.Rolandic Epilepsy
Phenytoin Absence epilepsy Progressive Myoclonus E
Phenobarbitone Absence epilepsy
Benzodiazepines Lennox-Gastaut syndrome
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AEDs which may aggravate some epileptic syndromes
Drug Syndrome
Vigabatrin Absence epilepsy Epilepsies with myoclonus
Gabapentin Absence epilepsy Epilepsies with myoclonus
Lamotrigine Severe myoclonic epilepsy Juvenile myoclonic epilepsy
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Paradoxical effects of AEDs CBZ in partial epilepsies;
FLE, BECTS, LKS, BEOP, Angelman’s syndrome Negative myoclonus & atypical absences Correlates with bilaterally synchronous
discharges in EEG I/V BZD precipitates tonic status in LGS,
even when child is already on oral BZDs
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Paradoxical effects of AEDs VPA increases absences in CAE LTG:
Precipiates absence seziures in BECTS Myoclonic status in LGS
Levitiracetum Seizure exacerbation in refractory
epilepsy with LEV at doses more than 30 mg/kg/d
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Are two drugs better than one?
Monotherapy can control seziures in 60%
When to start polytherapy?
When two monotherapy trials fail!
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Which initial drug?
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Initial treatment of idiopathic generalized epilepsy (expert committee)CLINICAL SITUATION GTCS ABSENCE S MYOCLONIC
EPILEPSY
Initial monotherapy ValproateLamotrigineTopiramate
ValproateEthosuximideLamotrigine
Valproate
Second monotherapy( Valproate failure)
LamotrigineTopiramateLevitirecetum
EthosuximideLamotrigine
ZonisamideLevitiracetumTopiramate
Second monotherapy( lamotrigine failure)
ValproateTopiramateLevitiracetumZonisamide
ValproateEthosuximide
Valproatezonisamide
Second monotherapy( Topiramte failure)
ValproateLamotrigine
ValproateEthosuximdeLamotrigine
Valproate
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If valproate fails If valproate fails as the first AED
Lamotrigine monotherapy is unlikely to be successful (Nicolson et al. 2004)
Prefer Topiramate or levetiracetam.
With generalized tonic-clonic seizures alone the choice is wider includes carbamazepine or oxcarbazepine in
addition
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Drugs recommended for focal epilepsy ( expert committee)SIMPLE PARTIAL
SEIZURECOMPLEX PARTIAL SEIZURE
SECONDARILY GENERALISED SEIZURE
Carbamazepine Carbamazepine Carbamazepine
Oxcarbamazepine Lamotrigine Oxcarbamazepine
Lamotrigine Oxcarbamazepine Lamotrigine
Levitiracetum levitiracetum Levitiracetum
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ILAE /AES Guidelines According ILAE treatment guidelines,
First-generation AEDs carbamazepine, phenytoin, and probably valproic acid have demonstrated effectiveness as monotherapy for partial-onset seizures.
According to AAN/AES subcommittees, Of the second generation AEDS, lamotrigine,
oxcarbazepine, and topiramate may be effective for monotherapy, although the ILAE has added that gabapentin,
and vigabatrin may also be efficacious or effective as monotherapy.
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Alternative choice in partial seizures
If carbamazepine is effective against seizures but poorly tolerated Try oxcarbazepine or lamotrigine next.
If carbamazepine fails to control seizures Levetiracetam or topiramate are likely to
be more powerful than gabapentin or lamotrigine
valproate remains an option.
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SANAD STUDYStandard and New antiepileptic Drugs
SANAD was an unblinded randomised controlled trial in hospital-based outpatient clinics in the UK
Aim is to study of effectiveness of carbamazepine, gabapentin, lamotrigine, oxcarbazepine, or topiramate for treatment of partial epilepsy:
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SANAD STUDY
Lamotrigine is clinically better than carbamazepine for time to treatment failure outcomes
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SANAD STUDY
Study of effectiveness of valproate, lamotrigine, or topiramate for generalised and unclassifiable epilepsy:
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SANAD STUDY
Valproate is better tolerated than topiramate and more efficacious than lamotrigine, and should remain the drug of first choice for many patients with generalised and unclassified epilepsies.
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PHARMACOTHERAPY OF EPILEPSY:
The issues Is treatment justified? When to start treatment? How to start drug treatment? Which AED? Risks associated AED treatment? Which dosage? When should AED combinations be
used? How long should treatment be
continued?
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Pharmacoresistent epilepsy If Patient fails on 2 or 3
monotherapy trials:
Polytherapy
Which drugs for add-on?
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RECOMMENDED AED COMBINATION
in Generalised seizureDRUG IN USE RECOMMEDED COMBINATION
Valproate LamotrigineTopiramateLevetiracetumzonisamide
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Drugs found to be useful asAdd-on in Primary generalised seizures ( by RCTS) Lamotrigine, Topiramate Felbamate and topiramate in LGS
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RECOMMENDED AED COMBINATION IN FOCAL SEIZURE
DRUG IN USE RECOMMEDED COMBINATION
Carbamazepine
LevetiracetumLamotrigineTopiramateZonisamide
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SUCCESS RATES OF NEWER AED for Partial seizure (As add–on)
27-29%: WITH OXC, Levitiracetam, topiramate
12-20% WITH
LTG, Gabapentin , Zonisamide
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COMPLAINTS RATES OF NEWER AED(as add on)
-28 TO -82 Gabapentin, Levitiracetam and
zonisamide
-113 to -205 OXC, topiramate and LTG
Hence the ideal drug is Levitiracetam.
OXC and Topiramate are equally effective but less tolerable.
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EPILEPSY - MANAGEMENTCHOICE OF DRUGS
ARE SPECIFIC COMBINATIONS USEFUL?
* Combination of VPA & Ethosuximide -- in absences * Combination of VPA & clonezepam -- In myoclonic seizure * Combination of CBZ & vigabatrin -- In partial seizure
* Combination of LTG & Valproate -- In partial, generalized,
JME
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How to combine drugs? Use AEDs with different mechanisms of action:
, e.g. a sodium channel blocker (carbamazepine) with a GABA-ergic agent (valproate);
Use AEDs with favourable pharmacokinetic interactions: e.g. valproate and lamotrigine.
(enabling lower doses of lamotrigine to be used);
Avoid combinations with similar mechanisms of action and/or unhelpful phamacokinetic interactions: e.g. Carbamazepine and phenytoin
Carbamazepine and Lamotrigine
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If combination therapy fails!
Consider surgery!
If this is not an option; Go back to the combination that gave
optimum, control
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INFANTILE SPASMS
ACTH, Vigabatrin Zonisamide ( open label studies) Levitiracetum
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PHARMACOTHERAPY OF EPILEPSY:
The issues Is treatment justified? When to start treatment? How to start drug treatment? Which AED? Risks associated AED treatment? Which dosage? When should AED combinations be
used? How long should treatment be
continued?
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Getting the dosage right
As important as choosing the right drug!
Some AEDs require slow titration e.g. CBZ, LTG, TPM and TGB
Dosage should be tailored to meet individual needs
Monitoring drug levels may help with dose tailoring
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EPILEPSY - MANAGEMENTDRUG DOSE & INTERVAL
May not always require the std dose. Gen. seizure requires less dose than partial Dose interval is determined by half -life
Eg: Pheno, DPH,LTG = OD
CBZ, VPA, Topiramate = BD Multiple AEDs = shorten half life Larger doses in children than adults
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DRUG INTERACTION
DPH
PBPMD
CBZ VPA
ETX
Enzyme induction
Enzyme inhibition
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DRUG INTERACTIONEffect of older AEDs on newer AEDs
GPBGabapentine
LTGLamotrigine
TPMTopiramate
TGNTiagabine
LEVLevetiracetam
ZONZonizamide
OXCOxcarbazepine
DPH
CBZ
PhenoPRM
None None
VPA None None None None None Slight
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DRUG INTERACTIONEffect of Newer AEDs on old AEDs
New AEDs have no significant effect on the blood level of old AEDs.
Phenytoin, carbamazepine, pheno or primidone
Valproate level is decreased by 25%
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DRUG –DRUG INTERCATION POTENTIAL OF THE AEDs
HIGH INTERMEDIATE MINIMAL OR NONE
phenytoin Topiramate Gabapentin
Carbamazepine lamotrigine Levitiracetum
valproate Tiagabine Vigabatrin
Phenobarbitone Oxcarbazepine
primidone zonisamide
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Pharmacotherapy in children Both old & newer drugs can be used Requires dose adjustments;
Slow GI absorption. Higher volume of distribution Shorter clearance periods
Eg: dose of CBZ infants : 30-50mg/KG Vs 15-35 mg/kg in older children
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Pharmacokinetics in children Pharmacokinetic Parametres in infants
VPA & Pb have favourable kinetics CBZ & DPH have unfavourable kinetics
CBZ dose is in higher & should be given tid dosage
DPH –difficult to determine adequate dose In view of non-linear pharmacokinetics Slight change in dose may produce toxicity/
subtherapeutic level Increased clearance of LTG and Topiramate
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PHARMACOTHERAPY OF EPILEPSY:
The issues Is treatment justified? When to start treatment? How to start drug treatment? Which AED? Risks associated AED treatment? Which dosage? When should AED combinations be
used? How long should treatment be
continued?
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Side effect profile of AEDS Quality of life
Not only related to the magnitude of seizure reduction
but also to the impact of the AED on cognition, mood (eg, depression, anxiety, and
irritability), psychomotor dysfunction, sexual dysfunction, cosmetic effects, bone health, weight gain etc.
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Risks associated with AED treatment Failure to achieve complete seizure
control
Dose-dependent CNS side effects
Idiosyncratic reactions
Chronic adverse effects
Adverse drug interactions
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The devil that we do not know:Latency to discovery of some adverse effectsDrug Adverse Effect Incidence Latent Period
PHT Osteomalacia Up to 5% 1938 1967
FBM Aplastic anaemia 1:4000 1993 1994
VGB Visual field defects 33% 1989 1997
TPM intraocular ? 1995 2001
pressure
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Side effects mandating stopping treatment:
Clobazam: Behavioral changes, irritabilty
Topiramate: Language disturbances, glaucoma
Levitiracetum: Mood and behavioral changes
Lamotrigine: Drug rash & SJ syndrome
Zonisamide: Mental slowing, hypohidrosis
Vigabatrin: Visual field defects
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Tolerability in infants & children
Valproate Valproate hepatotoxicity
Increased below the age of 2 yrs Polytherapy Presence of associated psychomotor delay
Look for undiagnosed inherited metabolic diseases Carnitine deficiency/ Alper’s disease
(Valproate interferes with mitochondrial function)
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Pharmacotherapy in children Valproate;
Preferably avoid in infants with Abnormal LFT, multiorgan failure, polytherapy or in those where exact aetiology is
unclear
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Tolerability in infants & children
Pheno induced behavioural side effects 1/3 develop hyperexcitability / insomnia
Benzodiazepines induced paradoxical hyperexcitation Bronchorrhoea / dysphagia with clonezepam
Vigabatrin Hypotonia & somnolence Retinal toxicity is less inchildren
Topiramate Metabolic acidosis is more in infants.
PHT worsens PME ( both myoclonus & ataxia)
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Emerging new AEDS
Brivaracetam. Derivative of levetiracetam. Mech of action;
It is a high-affinity synaptic vesicle protein 2A (SV2A) ligand
inhibitory activity at neuronal voltage-dependent sodium channels
High responder rate ( 55% versus 16%) Excellent tolerability
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Emerging new AEDS
Carisbamate. Adjunctive treatment for partial-onset
seizures It inhibits voltage-gated sodium channels has a broad-spectrum of activity in a
number of animal models of seizure and drug refractory epilepsy Responder rate( 28% versus 6%)
Mode of action: unknown Efficacy & tolerability data are limited
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Emerging new AEDS
Eslicarbazepine acetate. A voltage-gated sodium channel action
blocker, a prodrug that is structurally similar to
carbamazepine and oxcarbazepine. It has improved tolerability, Responder rate 41% versus 28% Once daily dosing is enough
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Emerging new AEDS
Lacosamide. Approved by FDA Adjunctive therapy for partial-onset seizures Oral and intravenous forms of this drug are
available. Responder rate (41% versus 20%) Unique action:
It selectively enhances slow inactivation of voltage-gated sodium channels without affecting fast inactivation
Lack of sedation, high intolerance rate
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Emerging new AEDS
Retigabine. Adjunctive therapy for partial-onset
seizures in refractory epilepsy, Acts on voltage-gated potassium
channels. It is a neuronal potassium channel opener
Responder rate (45% versus 15%) High discontinuation rate due to side
effects
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Emerging new AEDS
Rufinamide. Approved by FDA Adjunctive treatment of seizures
In Lennox-Gastaut syndrome Acts on sodium channel.
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Emerging new AEDS
Stiripentol.
This AED appears to enhance GABA release and has a positive effect on GABAA receptors.
It has been used in the treatment of Dravet syndrome (severe myoclonic epilepsy)i
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Emerging new AEDS undergoing trials
Flurofelbamate Ganaxolone Huperzine A Losigamone Safinamide Talampanal Tonabersat Valrocemide
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ADD SANAD STUDY
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Thank You
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Effect of non-AEDS on newer AEDs Rifampicin decrease the blood level
of lamotrigine; INH increases it.
Anti HIV agents increases the level of Lamotrigine, Levitiracetum & gabapentin
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AED & oral contraceptives Topiramate,oxcarbazepine, and
felbamate are weak inducers & can reduce the oral contraceptive effect.
AEDs that are safe to use in the presence of oral contraceptives include valproate, gabapentin, lamotrigine,
levetiracetam, and zonisamide.
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NEWER DRUGS IN STATUS:
i/v Valproate: i/v Levetiracetum; Oral Clobazam Oral Topiramate
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NEWER DRUGS IN STATUS:I/V valproate
CSF penetration is similar to I/V diazepam
Good alternative to phenytoin. Seizure control in 80% of patients More effective than Phenytoin (66% vs
42%) No significant side effect:
No sedation, No hypotension.
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NEWER DRUGS IN STATUS:I/V valproate Dose:
I/V bolus: adult dose: 15-30 mg/kg Children; 20-40 mg/kg
At the rate of 50mg /mt
Adverse effects: Hyperammonemic encephalopathy Pancreatitis Thrombocytopenia
Contraindication Children with acute liver failure Patients with inherited metabolic diseases
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NEWER DRUGS IN STATUS:I/V Levetiracetum
Advantages: Rapid titration. No drug interaction Good safety profile Excellent choice in hepatic failure
I/V dose; 1000 mg i/v
Efficacy: 100% efficacy in BZD resistant SE
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NEWER DRUGS IN STATUS:Topiramate
Oral loading Topiramate:
10mg/kg followed by 5mg/kg/day
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USE & SIDE EFFECT PROFILE
OF NEWER AEDS
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CLOBAZAM
Highly effective as an add-on Antiepileptic effect: Broad spectrum;
Partial, secondarily generalised, Absences, myoclonus LGS, ESES Alcohol withdrawal seizures Benign childhood partial epilepsies Intermittent therapy in catamenial
epilepsy
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CLOBAZAM
Side effects; Behavioral disturbances, irritability Sedation Tolerance
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Topiramate
Broad spectrum\: Partial, secondarily generalised Primary generalised LGS Childhood epilepsy syndromes Infantile spasms SMEI Atypical absence & tonic seizures
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Topiramate induced cognitive & langauge problems Risk factors:
Dependent on the rate of dose escalation the risk of cognitive dysfunction with predominant
word finding difficulties can be reduced if the dose is built up by no more than 25 mg per week or fortnight,
a family history of psychiatric disorder Family history of epilepsy history of febrile convulsions and generalised
tonic-clonic seizures
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Topiramate : other side effects Acute ocular problems;
Reduced visual acuity, myopia, and increased intraocular pressure
Combination of topiramate with valproate can be hepatotoxic.
Renal stones Hypohidrosis
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Levitiracetum
Broad spectrum; Partial seizures, secondarily generalised Photosensitive epilepsy Idiopathic generalised epilepsy Absences Myoclonus-JME
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Levitiracetum
Advantages: Highly effective Generally well tolerated No significant drug interaction
Main disadvantge: Mood & behavioral changes
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Zonisamide
Broad spectrum: Particularly useful in:
LGS, infantile spasms, PROGRESSIVE MYOCLONIC EPILEPSY
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Zonisamide;
Side effects; Ataxia, dizziness Mental slowing, Impaired concentration. Hypohidrosis-heat stroke Renal calculi Weight loss
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Lamotrigine
Broad spectrum: Partial, generalised. LGS, Infantile spasm
Advantage: Moderate effectiveness, well tolerated.
Main side effect: High instance of rash (appears within 4
weeks) Slow titration
Extensive drug interactions
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PHARMACOTHERAPY OF EPILEPSY: The issues
Is treatment justified? When to start treatment? How to start drug treatment? Which AED? Risks associated AED treatment? Which dosage? When should AED combinations be used? How long should treatment be
continued?
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# Factors to be considered:
1. Probability of relapse 2. Presence of adverse
effect 3. Psychological attitude 4. Legal implications
DRUG TREATMENT -When to stop?
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When to stop AED
Recurrence risk in all types of epilepsy after 2 years of seizure free period : 29%
Most Recurrences occur in the first year
If a patient is seizure free for more than 2 years after stopping treatment, subsequent recurrent risk is very low.
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When to stop AED
RISK FACTORS FOR HIGH RECURRENCE : Patients with abnormal EEG Known structural lesion and /or
neurol.deficit Occurrence of many seizures before control Long duration between therapy & seizure
control More than one type of seizure Adult onset complex partial seizure The seizure type
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When to stop AED
Early versus late withdrawal
( < 2 yrs)
Early discontinuation was associated with greater relapse rate in patients with partial epilepsy and in those with abnormal EEG
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PROGNOSIS OF EPILEPSY PROGNOSIS OF EPILEPSY RELAPSE RATE: # MOST IMPORTANT
PREDICATORS:
* Seizure type
myoclonic/atonic/tonic * Symptomatic partial * Syndromic forms eg: JME
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PROGNOSIS OF EPILEPSY PROGNOSIS OF EPILEPSY RELAPSE RATE:
# JME - 85 -95%
# GTC on awakening - 30-90% # Symptomatic partial - 25 -
75% # Childhood absence - 5 -25% # Benign rolandic epilepsy - 0%
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PROGNOSIS OF EPILEPSY PROGNOSIS OF EPILEPSY GOOD PROGNOSIS IN:
1. Febrile seizure 2. Benign rolandic epilepsy 3. Absence seizures 4. Idiopathic gen. tonic
clonic seizure ( with onset between 1
- 10 yrs)
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PROGNOSIS OF EPILEPSY PROGNOSIS OF EPILEPSY POOR PROGNOSIS IN:
1. Complex partial seizure 2. Symptomatic partial epilepsy 3. All forms of minor motor
seizures 4. Generalised tonic clonic
seizures ( With onset in infancy or
puberty)
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Thank You