Drug treatment of epilepsy

British Medical Journal, Jan 9, 1999 by Morgan Feely

([sections]) Most specialists would choose valproate for grand-mal seizures due to "primary generalised" epilepsy.

Table 2 Overview of current drug treatments for epilepsy

Drug                      Resume

Carbamazepine    Premier league: for partial or generalised
                 tonic-clonic seizures. Tolerability
                 generally good in children and younger
                 adults, relatively less good in elderly
                 people. Allergic reactions (rash) fairly
                 common. Enzyme inducing drug

Valproate        Premier league: for generalised (both
                 tonic-clonic and absence) and partial
                 seizures. Weight gain often a problem.
                 Allergic reactions uncommon. Not an
                 enzyme inducing drug

Lamotrigine      Recently promoted (monotherapy licence),
                 wide spectrum of activity; may join
                 first league. Allergic reactions (rash)
                 fairly common and occasionally severe

Phenytoin        Formerly in premier league, now used less
                 because of side effects. Spectrum
                 of activity similar to carbamazepine. Narrow
                 therapeutic window plus complex
                 pharmacokinetics demand monitoring of drug
                 concentration

Vigabatrin       Recent warning about visual field defects
                 makes specialist review desirable
                 (patients may require visual field testing)

Gabapentin       Not very effective as additional treatment
                 in severe epilepsy, but may have a
                 future as monotherapy

Clobazam         Has valuable special uses, particularly
                 when seizures occur in clusters

Topiramate       For treating severe epilepsy

Tiagabine        Just launched in Britain; place in clinical
                 practice still to be established

Phenobarbitone   Formerly used widely in cases of refractory
                 epilepsy; may still have a role when
                 other treatments fail. Specialist opinion
                 on withdrawal of drug is advisable

Primidone        Formerly used widely in cases of
                 refractory epilepsy

Clonazepam       Formerly used widely in cases of
                 refractory epilepsy; may still have a
                 role when other treatments fail. Specialist
                 opinion on withdrawal of drug is advisable

Ethosuximide     Alternative to valproate for petit mal
                 seizures only

                           Knowledge required by
                           non-specialist doctors

Drug               Know of    Know about    Know how to use

Carbamazepine        Yes         Yes              Yes

Valproate            Yes         Yes              Yes

Lamotrigine          Yes         Yes            Perhaps

Phenytoin            Yes         Yes            Perhaps

Vigabatrin           Yes        Perhaps            -

Gabapentin           Yes        Perhaps            -

Clobazam             Yes        Perhaps            -

Topiramate           Yes           -               -

Tiagabine            Yes           -               -

Phenobarbitone       Yes        Perhaps            -

Primidone            Yes           -               -

Clonazepam           Yes        Perhaps            -

Ethosuximide         Yes        Perhaps            -