THERAPEUTICS

Brands

• Trileptal, Oxtellar XR

Generic?

• Yes

Class

• Antiepileptic drug (AED)

Commonly Prescribed for

(FDA approved in bold)

• Partial seizures as monotherapy (≥ 4 years old) and adjunctive therapy (≥ 2 years old)

• Generalized tonic-clonic seizures

• Mixed seizure patterns

• Trigeminal neuralgia

• Temporal lobe epilepsy (children and adults)

• Neuropathic pain

• Alcohol withdrawal

How the Drug Works

• Primarily inhibits voltage-dependent sodium channel conductance

• Modulates calcium channels (N, P/Q type), potassium conductance, glutamate release, and NMDA receptors

How Long Until It Works

• Seizures: 2 weeks or less

• Trigeminal neuralgia or neuropathic pain: hours to weeks

If It Works

• Seizures: goal is the remission of seizures. Continue as long as effective and well tolerated. Consider tapering and slowly stopping after 2 years without seizures, depending on the type of epilepsy

• Trigeminal neuralgia: should dramatically reduce or eliminate attacks. Periodically attempt to reduce to lowest effective dose or discontinue

If It Doesn't Work

• Increase to highest tolerated dose

• Epilepsy: consider changing to another agent, adding a second agent, using a medical device, or a referral for epilepsy surgery evaluation. When adding a second agent, keep drug interactions in mind

• Trigeminal neuralgia: try an alternative agent. For truly refractory patients referral to tertiary headache center, consider surgical or other procedures

Best Augmenting Combos for Partial Response or Treatment-Resistance

• Epilepsy: drug interactions can complicate multi-drug therapy

• Pain: can combine with other AEDs (gabapentin or pregabalin) or TCAs

Tests

• Check sodium levels for symptoms of hyponatremia or in patients susceptible to hyponatremia

ADVERSE EFFECTS (AEs)

How the Drug Causes AEs

• CNS AEs are probably caused by sodium channel blockade effects

Notable AEs

• Sedation, dizziness, ataxia, headache, tremor, emotional lability

• Nausea, vomiting, anorexia, dyspepsia

• Blurry or double vision, upper respiratory tract infection, rhinitis

Life-Threatening or Dangerous AEs

• Rare blood dyscrasias: leukopenia, thrombocytopenia

• Dermatological reactions uncommon and rarely severe but include erythema multiforme, toxic epidermal necrolysis, and Stevens-Johnson syndrome. Drug reaction with eosinophilia and systemic symptoms (DRESS)/multi-organ hypersensitivity