Anti-seizure Medications (ASMs)

How many antiseizure meds are avaible?

More than 25.

How many dual therapy combinations are possible with ASMs?

More than 100 dual therapy combinations.

How do newer ASMs compare with older ASMs in efficacy?

Trials have found equal efficacy to older ASMs.

What type of ASM combinations should generally be avoided?

Combinations of medications with similar mechanisms of action.

What is rational polytherapy?

Combining drugs with different mechanisms of actions (MOA).

What factors should be considered when choosing an ASM?

Adverse effects, MOA, epilepsy syndrome/seizure type, age/gender, weight, comorbidites, lifestyle, cost, genetics, and formulations.

When was Phenobarbital approved?

1912.

Is phenobarbital broad or narrow spectrum?

Broad.

Who can receive phenobarbital?

Adults and children can receive phenobarbital.

Is phenobarbital effective in status epilpectiucs?

Yes particularly its IV formulation.

What are major adverse effects of phenobarbital?

Osteoporosis, high incidence of major congenital malformations (MCM), many medication interactions due to strong liver metabolism, bradycardia, and hypotension.

When was phenytoin approved?

1950s.

Is phenytoin broad or narrow spectrm?

Narrow spectrum.

Who can receive phenytoin?

Adults and children can recieve phenytoin.

Is phenytoin effective in status epilepticus?

Yeah phenytoin is effective using the IV formulation.

What are major adverse effects of phenytoin?

Osteoporosis, high incidence of MCM, fetal hydantoin syndrome, gingival hyperplasia, and worsening of absence seizures.

What is the black box waring for phenytoin?

Sever hypotension and cardiac arrhymia.

What are examples of second-generation ASMs?

Carbamazepine, gabapentin, pregabalin, lamotrigine, levitracetam, valporic acid, topiramate, and zonisamide.

What is gabapentin’s brand name?

Neuontin.

What is pregabalin’s brand name?

Lyrica.

What spectrum are gabapentin and pregabalin?

Narrow spectrum.

What is gabapentin’s major adverse effect listed in the notes?

Peripheral edema.

What is pregabalin’s major adverse effect?

Weight gain.

What are gabapentin and pregabalin also approved for?

Neuropathic pain.

What is an off-label use of gabapentin and pregabalin?

Anxiety.

What seizure type can gabapentin and pregabalin worsen?

Absence seizures.

Is lamotrigine broad or narrow spectrum?

Broad spectrum.

Who can receive lamotrigine?

Adults and children.

What psychiatric disorder is lamotrigine also approved for?

Bipolar disorder.

Who can receive lamotrigine?

Adults and children can take lamotrigine.

What psychiatric disorder is lamotrigine also approved for?

Bipolar disorder.

Which ASM is described as safest according to the AED pregnancy registry?

Lamotrigine.

What is the black box warning for lamotrigine?

Serious rash.

Why is slow titration recommended with Lamotrigine?

To reduce the risk of serious rash.

What is levetiracetam’s brand name?

Keppra.

Is levetiracetam broad or narrow spectrum?

Levetriacetam is broad spectrum.

Is levetiracetam effective in status epilpeticus?

Yes levitractam is effective in status epilepticus.

What psychiatric effects can levetiracetam cause?

Irritability, depression, and psychotic symptoms.

Does levetiracetam have drug-drug interactions?

No, levetiracetam does not have drug-drug interactions.

What should be considered when giving levetiracetam to patient with renal impariment?

Caution is needed.

Is valporic acid broad or narrow spectrum?

Valporic acid is narrow spectrum.

Is valporic acid effective in status epilepticus?

Yes, valporic acid is effective especially using the IV formulation.

What are the major adverse effects of valporic acid?

Weight gain, thrombocytopenia, and hepatotoxicity.

What is the black box warning for valporic acid?

High risk of MCM and autism spectrum disorder.

What is valporic acid’s position for women of childbearing potential?

It is considered the last option.

Is topiramate broad or narrow spectrum?

Topiramate is considered broad spectrum.

What are major adverese effects of topiramate?

Paresthesia, anorexia, weight loss, speech/cognitive disturbance, and kidney stones.

What congential abnormality is asssociated with topiramate?

Cleft palate, with a 16-fold increase.

What is another indication for topirmate?

Migraine prevention.

What is the brand name of lacosamide?

Vimpat.

Is lacosamide broad or narrow spectrum?

Broad spectrum.

Is lacosamide effective in stauts epilepticus?

Yes lacosamide is effective in status epilpeticus.

What cardiact effects can lacosamide cause?

Prolonged PR interval and atrial arryhtmia.

What should be obtained before starting lacosamide in relation to cardiac risk?

A pre treatment EKG because of possible 2nd and 3rd degree block.

Does lacosamide have many medication interactions?

No Lacosamide has minimal medication interaction.

What is the brand name of perampanel?

Fycompa.

What is the half-life of perampanel?

105 hours, allowing once-daily dosing.

What is the black box warning for perampanel?

Homicidal ideation.

What psychiatric effects can perampanel cause?

Hostility and irritability.

Does perampanel have medication interactions?

Yes.

What is clobazam?

A modified benzodiazepine.

Is clobazam broad or narrow spectrum?

Clobazam is Broad spectrum.

What is the black box warning for clobazam?

Addiction, abuse, and dependence.

What are examples of newer ASMs?

Oxcarbazepine, eslicarbazepine, cannabidiol, cenobamate, fenfluramine, and brivarcetam.

What spectrum are oxcarbazepine and eslicarbazepine?

Oxcarbazepine and eslicarbazepine are narrow spectrum.

What are major adverse effects of oxcarbazepine/eslicarbazepine?

Hyponatremia and skin rash.

What additional properties do oxcarbazepine/eslicarbazepine have?

Mood stabilization and benefits for neuropathic pain.

What is cannabidiol in the context of the hospital?

Highly purified CBD, FDA regulated, with no THC.

Is cannabidiol broad or narrow spectrum?

Broad spectrum.

What formulation of cannabidiol is available accoridng to the notes?

Oral solution only.

What are important adverse effects/interactions of cannabidiol?

Liver injury and increased clobazam levels.

What effect does food have on cannabidiol absorption?

Food increases absorption.

What is the brand name of cenobamate?

Xcopri.

Is cenobamate broad or narrow spectrum?

Cenobamate is narrow spectrum.

Who is cenobamate indicated?

Adults >_ 18 years old.

What is cenobamate’s half-life?

50-60 hours, allowing once-daily dosing.

What serious hepatic adverse effects can cenobamate cause?

Rare hepatic failure.

What should be monitored with cenobamate because of hepatic risk?

Liver enzymes.

What EKG change can cenobamate cause?

QT interval shortening.

Why is slow titration used with cenobamate?

A slow titration schedule is recommended for cenobamate.

Approximately what proportion of patients in clinical studies became seizure-free with cenobamate?

About 1/5 of patients.

Is fenfluramine broad or narrow spectrum?

Broad spectrum.

What formulation of fenfluramine is available?

Oral solution only.

What monitoring program is mandatory with fenfluramine?

A cardiac monitoring program with serial echocardiograms.

What serious condition should be conisdred with fenluramine?

Serotonin syndrome.

What is the brand name of brivacetam?

Brivact.

Is brivacetam broad or narrow spectrum?

Brivacetam is narrow spectrum.

What psychiatric effects can brivarcetam cause?

Anger and pschosis.

Does combining brivacectam with keppra provide added efficacy?

No combining brivacetam with keppra does not provide efficacy.

is brivacetam available generically?

Yes brivacetam is available generically.

What type of ASMS are genearlly used for focal epilepsy?

Narrow-spectrum and broad-spectrum ASMs.

What can broad-spectrum ASM-s treat?

Both focal and generalized onset seizures.

What type of ASMs are generally used for genearlzied epilepsy?

Broad-spectrum ASMs.

What seizure types can some narrow-spectrum ASMs worsen?

Absence and myoclonic seizures.

What rescue meidcations are listed for acute repetitve seizures?

Diazepam (Valtoco) and midazolam (Nayzilam).

Which ASMs can worsen psychiatric history?

Levetiracetam and brivaractam.

Which ASMs can improve psychiatric symptoms?

Lamotrigine, oxcarbazepine, and valporic acid.

Which ASMs can worsen obseity?

Valporic acid, pregabalin, and gabapentin.

Which ASM can improve obesity/assist with weight loss?

Topiramate.

Which ASMs can imporve migraine?

Topiramate, valporic acid, and lamotrigine.