I usually start my patients with 0.5 mg at night, and if they are not too sleepy the next day, increase to 0.5 mg twice a day. More so than most, its effects wear off over time. Side effects of clonazepam include sedation, thinking/memory impairment, mood changes, addiction. Benzodiazepines increase the effectiveness of GABA, the brain’s main inhibitory neurotransmitter. Benzodiazepines are used as anti-seizure drugs, sedatives, tranquilizers and muscle relaxants. clonazepam (Klonopin): Clonazepam is a member of the drug class known as benzodiazepines, to which diazepam (Valium), lorazepam (Ativan), clorazepate (Tranxene), alprazolam (Xanax) also belong. A week later, if seizures persist, I will increase to 0.5 mg three times a day. See information on clonazepam. Clonazepam is more long-acting against seizures than are diazepam or lorazepam. A typical adult dose is 0.5-1.0 mg three times a day.
VPA has effects on GABA (at least in very high doses), and a neurotransmitter called NPY to block seizures, and maybe also on calcium channels. valproic acid (Depakote): This is the standard broad-spectrum AED (treats all types of seizures) and no other AED is more effective for generalized seizure types. Typical adult dose is 250 mg - 500 mg three times a day, but dose can be higher. VPA has significant side effects: weight gain, tremor, hair loss, GI upset, blood count decreases, hepatic or pancreatic injury, bone weakness over time (osteoporosis), birth defects in up to 10% (folic acid can help to prevent them). See information on valproic acid. An extended release form can be taken once a day.
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Typical adult dose is 100-300 mg twice a day. If there are no significant side effects, I then switch my patients to 100 mg pills and increase to 200 mg twice a day over the next few weeks. Some find less cognitive impairment than with topiramate but this is individual and dose-dependent. zonisamide (Zonegran): Zonisamide is rather similar in its coverage and side effects to topiramate, except glaucoma is not usually listed. See information on zonisamide. I usually start my patients with one 25 mg pill daily, adding 25 mg each week on a two-times-a-day schedule until taking 100 mg twice a day.
People who have the “short QT syndrome,” a rare heart rhythm irregularity, should not take Banzel. Banzel works on sodium channels in brain cells, in a way to make them less excitable. This syndrome can include seizure types such as atonic (drop) seizures, tonic (stiffening) seizures, myoclonic (brief jerking) seizures, or staring (absence) seizures, as well as partial seizures. See information on rufinamide. The drug comes as 200 and 400 mg tablets. Common side effects include headache, dizziness, fatigue and sleepiness, double vision and tremor (trembling). Dosing can increase by adding additional 10 mg/kg amounts every two days, until the child is taking 45 mg/kg/day or a maximum of 3200 mg/day, divided into two doses each day. Children will usually be started at doses of approximay 10 mg/kg/day administered in two equally divided doses. rufinamide (Banzel, Inovelon in Europe): Banzel is approved for add-on treatment of children age 4 and older and adults with Lennox Gastaut Syndrome.
See information on lamotrigine. lamotrigine (Lamictal): A broad-spectrum alternative to VPA, with a better side effect profile. This is slower than the package insert suggested starting dose, however, a slow starting dose is especially important if the patient also takes valproic acid (Depakote), to reduce risk for rash. I usually start my patients at low doses, adding one 25 mg pill daily each week on a two-times-a-day schedule until taking 100 mg twice a day. Severe medical side effects are unusual. I then switch my patients to 100 mg pills and increase to 200 mg twice a day over the next few weeks. If there is no rash at that time, one is unlikely. Therefore, it takes a couple of months to get up to the typical adult dose of 200 mg twice a day. Lamotrigine is also used for mood stabilization. Lamotrigine works by several mechanisms including blocking release of glutamate, the brain’s main excitatory neurotransmitter. The practical side effect issue is rash, occurring in several percent of people who take it, especially if the dose is increased too fast. It has the usual side effects of dizziness and fatigue, usually mild cognitive (thinking) impairment. However, LTG may not be as effective for myoclonic seizures.
The target serum level is 10-40 mcg per ml. Watch for sedation, thinking/memory problems and depression. I start my patients with 30 mg pills, 2 or 3 at bedtime, to allow for future dosage flexibility. phenobarbital (Luminal): The old-timer: very inexpensive and effective in a single daily dose. Phenobarbital is mildly addictive and requires slow withdrawal. Phenobarbital increases the effect of GABA, the main inhibitory neurotransmitter in the brain. During pregnancy, there is a significant rate of birth defects. Phenobarbital can cause long-term bone problems. See information on phenobarbital. Typical adult dose is around 100 mg per day.
oxcarbazepine (Trileptal): Slightly different from carbamazepine, it is at least as effective, and may have fewer side effects, except for more risk for low blood sodium (hyponatremia). I start my patients with 150 mg twice a day, and increase by 150 mg daily each week. It is more expensive than generic carbamazepine. An immediate switch from carbamazepine to full-dose oxcarbazepine is possible in some cases. A typical adult dose is 600 mg twice a day. See information on oxcarbazepine. This is slower than the package insert suggested starting dose.
Side effects are unsteadiness, weight gain, fatigue, dizziness. gabapentin (Neurontin): Gabapentin has the reputation of being a safe but not particularly powerful AED. Typical adult dose is 300-600 mg three times a, but doses can be up to 1200 mg three times a day. Gabapentin often is used also for chronic pains of certain types. It has no drug interactions, is not metabolized in the liver and it does not bind to blood proteins. I often start at 300 mg per day, sometimes in one dose or with 100 mg pills, and increase over a month or two to the full dose. The drug probably works by influencing transport of GABA and effects on calcium channels. The effectiveness criticism probably is because it is often prescribed at too low a dose. See information on gabapentin.
Phenytoin can be started quickly in an emergency with intravenous administration, or a large dose of capsules if an immediate effect is required. Small changes in phenytoin dose can cause large changes in serum drug levels, so the blood levels can be hard to regulate. Phenytoin causes a rash rate of a few percent, sometimes even the dangerous rash called Stevens-Johnson syndrome. phenytoin (Dilantin): The most used AED by general physicians in the US, less so by epilepsy doctors, because of the side effects. It is inexpensive. Common side effects are unsteadiness and moderate cognitive problems. See information on phenytoin. Phenytoin alters brain cell sodium channels, which has the effect of limiting rapid firing of the brain cells. Typical adult dose is 300-400 mg per day, usually with 100 mg pills. The target serum level is 10-20 mcg per ml. There are long-term potential cosmetic (body/face hair growth, skin problems), and bone problems (osteoporosis).
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Others: acetazolamide (Diamox), diazepam rectal gel (Diastat), ethosuximide (Zarontin), felbamate (Felbatol), primidone (Mysoline), and tiagabine (Gabitril) can be searched individually on.
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It works reasonably quickly when taken orally and anti-seizure effect lasts for 2-6 hours. A lorazepam concentrate, 2 mg per ml, can be taken as 1 ml liquid under the tongue in urgent situations. lorazepam (Ativan): Lorazepam is similar to clonazepam in dosage and action, but it is not as long-acting. See information on lorazepam. Typical adult dose is 0.5-2.0 mg orally or as needed. It is usually used as a ‘rescue medication’ for patients who frequently have clusters of seizures.
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It also may be very effective for infantile spasms, a serious type of seizures in young children. Release in the US was delayed because the drug is toxic to the retina of the eye in up to 30% of people who take it long-term. vigabatrin (Sabril): At time of this writing, vigabatrin is approved in the US, but official package insert information has not become available. Vigabatrin is a “designer drug,” made to block metabolism of GABA, the brain’s main inhibitory neurotransmitter. Sabril has been used for over a decade in many countries, and it is effective for partial seizures, with or without secondary generalization. Regular vision testing is recommended for all people on this drug. This toxicity can result in permanent loss of peripheral vision. A typical regimen begins with 500 mg twice a day, and can increase over a month or two to 1500 mg twice a day. See information on vigabatrin.
Side effects include thinking and memory problems in about 1/3rd, renal stones in 1-2%, rare cases of glaucoma (increased eye pressure) and weight loss. More acidity (to a point) suppresses seizures. See information on topiramate. Topiramate also is used for migraine headache prevention. Typical adult dose is 150-200 mg twice a day. Topiramate has several mechanisms, including blocking the enzyme carbonic anhydrase, which affects the acidity of brain tissue. topiramate (Topamax): A good broad-spectrum AED (i.e., treats all types of seizures). I usually start my patients with one 25 mg pill daily, adding another pill each week on a two-times-a-day schedule until taking 100 mg twice a day. If there are no significant side effects, I then switch my patients to 100 mg pills and increase to 200 mg twice a day over the next few weeks.
It is chemically related to the amino acid, serine. Side effects include dizziness, headache, nausea or vomiting, double vision, fatigue, memory or mood problems. lacosamide (Vimpat): Lacosamide is a new (2009) antiepileptic drug, for partial and secondarily generalized seizures. The recommended starting dose is 50 mg twice daily, increased each week by an extra 100 mg, to the recommended maintenance dosage of 100-200 mg twice a day. Vimpat may affect the internal organs, blood counts or heart rhythm, but these potentially serious side effects are infrequent. Vimpat blocks sodium channels (but in a different way from other seizure medicines), and this block reduces brain excitability. See information on lacosamide.
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No drug companies have paid for or reviewed these opinions. This summary represents the opinion of the author, Dr. has a great section on antiepileptic drugs (AEDs), but I often have been asked for a brief summary document that pulls the information into one package. Robert Fisher, who is an epilepsy specialist, and it is not necessarily the official drug description that can be found in the package insert.
This is slower than the package insert suggested starting dose. This may occur to some degree in up to a third of those taking the medicine. The most common side effects are dizziness, fatigue, insomnia, but the more troublesome problem can be irritability and mood changes. See information on levetiracetam. It has no drug interactions, is not metabolized in the liver and it does not bind to blood proteins. I usually start my patients with 250 mg twice a day and increase the next week to 500 mg twice a day, then the next week to 1000 mg in the am plus 500 mg in the pm, then the week after to 1000 mg twice a day. levetiracetam (Keppra): Levetiracetam is one of the more used medicines in seizure clinics because it probably is effective for a broad-spectrum of seizures types, has a relatively low incidence of causing thinking/memory problems, and can be started at 500 mg twice a day, which is an effective dose. A typical adult dose is 500 - 1500 mg twice a day.
This is slower than the package insert suggested starting dose, but avoid sedation. Pregabalin often is used also for chronic pains of certain types. Pregabalin has no drug interactions, no liver metabolism, no protein binding, and similar side effects to gabapentin. I usually start my patients with 50 mg daily, adding 50 mg each week on a twice a day basis until taking 300 - 600 mg per day. Typical adult dose is 150 - 600 mg bid. pregabalin (Lyrica): A relative of gabapentin, it may be better, and can be given twice a day. See information on pregabalin. Some believe that it is more effective against seizures than is gabapentin.
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Potential side effects include GI upset, weight gain, blurred vision, low blood counts, low blood sodium (hyponatremia). Long-acting forms such as Carbatrol or Tegretol-XR can be given once a day. I start my patients with 200 mg bid and each week, and increase by 200 mg daily to about 400 mg three times a day. Carbamazepine affects sodium channels, and inhibits rapid firing of brain cells. Carbamazepine causes a rash rate of a few percent, sometimes even the dangerous rash called Stevens-Johnson syndrome. Typical adult dose is 400 mg tid. carbamazepine (Tegretol, Carbatrol): A favorite partial seizure medicine in the developed world. See information on carbamazepine and information about carbamazepine extended release. People of Asian descent with HLA-B*1502 antigen are more at risk.
The narrow spectrum AEDs mostly work for specific types of seizures (such as partial, focal, or absence, myoclonic seizures). No one medicine dominates for effectiveness, and all have various side effects. Broad spectrum AEDs additionally have some effectiveness for a wide variety of seizures (partial plus absence myoclonic seizures). There is no formula to choose which seizure medicine to use for a particular patient. Doctors and patients choose AEDs after considering which side effects should be avoided in particular cases, convenience of use, cost and physician experience. An important start is to know which AEDs work for which seizure types. ( Go here to learn what these seizures types are ). Some types of seizure are difficult to treat with any AED.Which of the following is not true of antiseizure medications?