Seizure disorders

Use at a glance

• Choose ASM by seizure type/syndrome

Treatment options

• Surgery/device/diet options can be disease-changing

Other treatment options

• Broad-spectrum drugs cover mixed/generalized syndromes
• Focal drugs differ from absence/myoclonic priorities
• After 2 appropriate drug failures → epilepsy-center referral

Safety / pitfalls

• Avoid abrupt ASM withdrawal

Key points

• ASMs ≈ equal efficacy per seizure type; choose by spectrum, AEs, interactions, comorbidities, cost
• Start monotherapy, titrate to control or intolerable AEs; try 1–2 alternative monotherapies before combining
• ILAE renames: partial→focal onset; primary generalized→generalized onset; secondarily generalized→focal to bilateral tonic-clonic
• FDA adjunct-only focal ASMs often effective as monotherapy and for other seizure types
• Focal: carbamazepine, lacosamide, lamotrigine, levetiracetam, oxcarbazepine; GTC/myoclonic/atonic/atypical absence: lamotrigine, levetiracetam, valproate; absence: ethosuximide, valproate
• Teratogenicity lowest: lamotrigine, levetiracetam, oxcarbazepine; highest: valproate → not 1st-choice if childbearing potential
• Generic substitution: no change in seizure frequency/tolerability; keep same manufacturer if possible

Pearls

• Phenobarbital: effective but more sedating; first-line for neonatal seizures
• Enzyme inducers and valproate raise osteoporosis risk
• Lamotrigine, levetiracetam levels fall in pregnancy; doses may need raising
• Folic acid ≥0.4 mg daily before and during pregnancy
• Seizures usually riskier to the fetus than ASMs

Self-check

• Which ASM stopping pattern is avoided?
  Abrupt ASM withdrawal.
• What follows 2 appropriate ASM failures?
  Epilepsy-center referral.

Drugs used for this (34)

All clinical uses · Open Seizure disorders in the interactive console ↗