Anti Epileptic Drugs (AEDS) CHOICE -DR GANESH.pptx

HOW TO CHOOSE AEDS
Dr. Ganeshgouda Majigoudra
Consultant Neurologist
Nanjappa hospitals Davanagere
ganeshgoudam4@gmail.com
9380906082

INDEX
• Brief about epileptic syndromes
• Principles of Treatment
• AED Selection
• AEDs – Special Population
• Case scenario
• Anti – Epileptic Drugs

DEFINE EPILEPSY RULE OUT MIMCS FIRST, BEFORE AED
RIGHT FOCAL MOTOR
ONSET TO BILATERAL
TONIC CLONIC,FRONTAL
LOBE EPILEPSY(LATERAL
PREFRONTAL, DOMINAT
LOBE)- STRUCTURAL
ETIOLOGY,
DEPRESSION/COGNITIVE
DELAY

PRINCIPLES OF ANTIEPILEPTIC DRUG PRESCRIBING IN
PATIENTS WITH NEWLY DIAGNOSED EPILEPSY - 1
• Aim for complete control without adverse effects
• Diagnosis of epileptic seizures should be proper
• Seizure type, syndrome and etiology should be Established
• Baseline hematological and biochemical investigations
should be performed before initiation of drug therapy
• Use one drug at a time (monotherapy) at least initially

PRINCIPLES OF ANTIEPILEPTIC DRUG PRESCRIBING IN
PATIENTS WITH NEWLY DIAGNOSED EPILEPSY - 2
• Initial titration should be to low maintenance doses
• Further upward titration will depend on response and side effects
• If first drug fails, alternative monotherapies should be Tried
• Upward and downward titration should be in slow, stepped doses
• Polytherapy should be used only if monotherapy with at least the first
three drugs chosen has failed to control Seizures
• Patients should be fully counselled about goals, role, risk, outcome and
logistics of drug treatment

FACTORS INFLUENCING CHOICE OF TREATMENT IN EPILEPSY
• Age and gender
• Co - morbidity (physical and mental)
• Social circumstances (employment, education, domestic, etc.)
• Emotional circumstances
• Attitude to risks of seizures and of medication
• Factors related to the epilepsy
• Syndrome and seizure type
• Severity and chronicity
• Etiology
• Factors related to the drug
• Drug interactions and pharmacokinetic properties
• Cost

PRINCIPLES OF AED Rx
AED -
SELECTION
SEIZURE
TYPE
PATIENT
PROFILE
SPECIAL
POPULATION

AED Selection ??
• 1. Is AED treatment justified?
• 2. When to start treatment?
• 3. Which AED?
• 4. What dosage?
• 5. When should AED combinations be used?
• 6. Risks associated AED treatment?
• 7. How long should treatment be continued?
• 8. Cost

1. Is AED treatment justified?
• Of patients diagnosed with epilepsy , 20% to 30% are found
to have been misdiagnosed
• Common misdiagnosis:
• A.Psychogenic nonepilepticattacks
• B.Syncope
• C.Other organic conditions
• 1.Hypoglycemia
• 2.Panic attacks
• 3.Paroxysmal movement disorders
• 4.Sleep disorders
• 5.Migraine
• 6.TIA
• 7.TGA

2. When to start treatment?
• Unprovoked First Episode ?

Risk Classification

• When to treat seizures with AEDs?
➡ 2 unprovoked seizures occuring > 24 hrs
apart
➡ Consider treatment if (⬆risk): abnormal
MRI, EEG, neuro exam, remote brain
injury/lesion, nocturnal, Presenting in status
epileptics

• Recurrence after 1st unprovoked = 21-45% (<
2 yrs)
➡ After 2nd unprovoked = 57% (by 1 yr),
73% (by 4 yrs)
➡ Immediate Rx after 1st unprovoked ⬇
recurrence in first 2 years but not change to
long-term remission (>3 yrs), & at risk of AED
side effects (7-31%).

BRIVARACETAM 2016
(CLASSICAL ASM)
3. Which AED?

Patient characteristics Drugs that are particularly
suitable
Drugs that should be
particularly avoided
Patients who wish particularly to
avoid cosmetic effects
Phenobarbital, phenytoin,
valproate (for its effects on
hair)
Patients with prominent anxiety Clobazam (and other
benzodiazepines),
carbamazepine, gabapentin,
phenobarbital, pregabalin,
valproate
Levetiracetam
Patients with prominent
depression
Carbamazepine,
lamotrigine, valproate
Levetiracetam, vigabatrin,
phenobarbital
Patients with renal stones Acetazolamide, topiramate,
zonisamide
3. Which AED? – Pt Profile

Patient characteristics Drugs that are particularly
suitable
Patients with migraine Topiramate, valproate
Patients with the need to lose
weight
(or not to gain weight)
Topiramate, zonisamide Gabapentin, pregabalin,
valproate
Patients with hyponatraemia Carbamazepine, oxcarbazepine
Patients at particular risk from
allergy
Clobazam, gabapentin,
lacosamide,
levetiracetam, pregabalin,
topiramate,
vigabatrin
Acetazolamide,
carbamazepine,
felbamate, lamotrigine,
oxcarbazepine,
phenytoin, zonisamide
Patients at particular risk of
heart
disease
Carbamazepine, lamotrigine,
oxcarbazepine
3. Which AED? - Pt Profile

Patient characteristics Drugs that are
particularly suitable
Patients at risk from
osteoporosis
Gabapentin,
levetiracetam,
pregabalin
Phenobarbital, phenytoin
Patients in whom the risk of
hepatic enzyme interactions
have to be avoided (e.g.
those co - mediated with
antibiotics,
immunosuppressive drugs,
oncological drugs,
antipsychotics)
Clobazam, gabapentin,
lacosamide,
levetiracetam,
pregabalin, topiramate,
vigabatrin
3. Which AED? - Pt Profile

Seizure type Drugs that can worsen seizures
Partial seizures,
secondarily generalized
tonic– clonic seizures,
primary generalized
tonic– clonic seizures
Absence seizures
(typical absence)
Carbamazepine, gabapentin,
phenytoin, pregabalin, oxcarbazepine,
tiagabine, vigabatrin
Myoclonic seizures Carbamazepine, gabapentin,
lamotrigine, oxcarbazepine, phenytoin,
pregabalin, tiagabine, vigabatrin
Atypical absence, tonic
and atonic seizures
Carbamazepine, gabapentin,
oxcarbazepine, phenytoin, pregabalin,
tiagabine, vigabatrin
3. Which AED? – Worsen Seizure!

• Newer versus older drugs
• No major differences in efficacy between
drugs
• Major differences in side effects profiles
• Drug interaction potential also differs
• Drug choice should be tailored to the patient
3. Which AED?

6. Risks associated AED treatment?
• Carbamazepine: Skin Rash, Hyponatremia
• Valproate: Weight gain , Hair loss
• Phenytoin: Gum Hypertrophy
• Clobazam: Behavioral changes, irritabilty
• Topiramate: Language disturbances, Renal Calculi
• Levetiracetam: Mood and behavioral changes
• Lamotrigine: Drug rash & SJ syndrome

6. Risks associated AED treatment?

7. How long should treatment be
continued?
• Factors to be considered to stop treatment:
• 1. Probability of relapse
• 2. Presence of adverse effect
• 3. Psychological attitude
• 4. Legal implications

continued?
• When to stop AED…
• Recurrence risk in all types of epilepsy after 2
years of seizure free period : 29%
• Most Recurrences occur in the first year
• If a patient is seizure free for more than 2 years
after stopping treatment, subsequent recurrent
risk is very low.

continued?
• RISK FACTORS FOR HIGH RECURRENCE :
• Patients with abnormal EEG
• Known structural lesion and /or neuro deficit
• Occurrence of many seizures before control
• Long duration between therapy & seizure control
• More than one type of seizure
• Adult onset complex partial seizure
• The seizure type

8. AED - COST
DRUG 10Tabs
LEV – 500mg 106/-
OXCBZ 300mg 84/-
Lacosamide 200mg 140/-
Clobazam 53/-
Phenytoin 100mg 1 Bottle= 100Tabs = 133/-

EPILEPSY IN ELDERLY
• Epilepsy in elderly people is now the third most common
neurological condition after dementia and stroke.
• Epilepsy is the first manifestation of previously silent
cerebrovascular disease
• Drug - induced epilepsy is common in elderly people because of the
complex pharmacokinetics.
• Annual incidence rates :
• 87 per 100 000 in the 65 – 69 age group,
• 147 per 100 000 of people in their 70s, and
• 159 per 100 000 of people in their 80s

EPILEPSY IN ELDERLY
• Half - life of many drugs is longer than in young
adults.
• Protein binding may be reduced as albumin
concentrations are lower in elderly people.
• Clearance is often lower in elderly people due to
reduced hepatic capacity and lower glomerular
filtration rates

EPILEPSY IN ELDERLY
• More sensitive to the neurological side effects
of drugs
• Lower drug doses are sufficient to control
seizures in elderly people compared with
younger adults.

EPILEPSY IN ELDERLY
• Membrane - stabilizing drugs (e.g. phenytoin,
carbamazepine, lamotrigine) - Arrhythmia and
hypotension
• Loss of bone mass - phenytoin, carbamazepine
or phenobarbital, a particular risk in
postmenopausal women.
• Carbamazepine has an anticholinergic effect that
can precipitate urinary retention.

EPILEPSY IN WOMEN
• In one UK- study, the overall fertility rate was
47.1 live births per 1000 women with
epilepsy per year compared with a national
rate of 62.6.

PREGNANCY
• Pregnancy, particularly in the last trimester, can exert marked effects on
the pharmacokinetics of antiepileptic drugs.
• Serum levels of phenobarbital and phenytoin can fall by up to 40% during
pregnancy, and rise to pre - pregnancy levels in the first month after
delivery.
• Similar falls in the active metabolites of oxcarbazepine and levetiracetam
are reported.
• Carbamazepine levels decline less in general and this is another reason
for choosing this drug in pregnancy.
• The greatest problems seem to arise with lamotrigine, with levels falling
in some patients by 60% and, if there is a fall, this is reversed in the few
days postpartum.

TERATOGENICITY
• The risk of spina bifida has been particularly well
studied.
• The background population risk of spina bifida is
approximately 0.2 – 0.5% with geographical variation.
• Valproate is associated with a 1 – 2% risk of spina
bifida, a risk that is dose related.
• Carbamazepine carries a risk of spina bifida of about
0.5 – 1%.

PCOS
• Initial studies from Finland suggested that valproate
therapy in particular induces PCOS.
• In one study, 30 – 40% of patients taking valproate
therapy had polycystic ovaries and hyperandrogenism,
compared with 5 – 15% of those taking
carbamazepine or lamotrigine.
• 44% of those valproic acid compared with 23% of
those on lamotrigine if treatment was initiated before
age 26 years, whereas the rates were similar (24% vs
22%) if treatment was started after age 26 years.

CATAMENIAL EPILEPSY
• Oestrogen is mildly epileptogenic, and the
high oestrogen concentration in the follicular
phase of the menstrual cycle is a possible
underlying cause for the greater propensity to
seizures at this time.
• Premenstrual tension and water retention
are other possible contributory factors.

CATAMENIAL EPILEPSY
• Therapy with diuretics or acetazolamide for 5
– 7 days has not proved generally successful.
• Clobazam, improvement noted in one study in
78% of women

labour and delivery.
• Seizures are particularly likely around the time of
• Most new - onset seizures in the late stages of
pregnancy (after 20 weeks) are caused by eclampsia.
• Pre – eclampsia is characterized by hypertension,
proteinuria, oedema, and abnormalities of hepatic
function, platelets and clotting parameters.
• About 1 – 4% of cases progress to eclampsia.

• Magnesium sulphate is given intravenously as a
loading dose of 4-6 g over 20 min followed by a
maintenance dose of 1 – 2 g/h as a continuous
intravenous infusion.
• MgSo4: MA:
• influence on N - methyl - d - aspartate (NMDA)
receptors or on free radicals, prostacyclin, other
neurochemical pathways or, more likely, by reversing
the intense eclamptic cerebral vasospasm.

• In patients at risk, oral clobazam (10 – 20 mg)
is useful when given at the onset of labour as
additional seizure prophylaxis.
• Intravenous lorazepam or phenytoin should
be given during labour if severe seizures occur
and the patient should be prepared for a
caesarean section.

IGE - PREGNANCY
• IGE : VALPROATE
• Pregnancy - Teratogenicity

IGE - PREGNANCY
• Lamotrigine is an alternative but often less effective
and its prescription in pregnancy is associated with
Pharmacokinetic and other problems.
• The handling of levetiracetam may be less problematic
in pregnancy but data on pregnancy outcomes are
insufficient at present to guarantee safety and lack of
teratogenicity.
• carbamazepine is often recommended which controls
tonic – clonic seizures to the same extent as valproate
in cases of IGE but can aggravate myoclonic seizures.

TERATOGENICITY - PREVENTION
• AED - Therapy review
• As most of the major malformations are established
within the first trimester, many within the first 8 weeks,
optimization of therapy should be carried out before
conception.
• Referral of a woman for a review of drug therapy when she
is 10 weeks ’ pregnant is too late to make changes that will
minimize the teratogenic risks.
• -

• 1. 24 Yrs Female – Epilepsy
• A. Planning Marriage
• B. UPT – Positive
• C. First – Second – Third Trimester
• D. Labour
• E. IGE
• F. Migraine

• 2. 25 Yrs Male –
• A. Hypersensivity
• B. Thin
• C. Obese
• D. Psychosis

• 3. 45 Yrs Old Male –
• A. CLD
• B. CKD
• C. D. CCF – Arrhythmias
• E. Hyponatremia
• F. TB / HIV
• G. HIE

 DRUG: Carbamazepine
• MA: Inhibition of sodium channel conductance
• DOSE:
• Usual dosage – adults
• Initial: 100 – 200 mg at night; increased by increments of 200 mg every 2 weeks
• Maintenance: 400– 1600 mg/day (maximum 2400 mg)
• Usual dosage – children
• < 1 year, 100 – 200 mg/day (initial dose 50 mg/day)
• 1– 5 years, 200– 400 mg/day (initial dose 100 mg/day)
• DOSING INTERVAL: 2 – 3 times/day

• ORAL B.A: 75 – 85%
• TIME TO PEAK: 4 – 8 h
• METABOLISM: Hepatic epoxidation and hydroxylation, and then conjugation
• HALF LIFE: 5 – 26 h
• DOSE AFFECTED BY : Severe hepatic disease
 DRUG: Carbamazepine
• PRIMARY INDICATIONS:
• Monotherapy and adjunctive therapy in partial and generalized seizures (excluding absence,
tonic and myoclonic seizures) and in childhood epilepsy syndromes. Adults and children
• SIDE EFFECTS:
• Drowsiness, fatigue, dizziness, ataxia, diplopia, blurring of vision, sedation, headache,insomnia,
gastrointestinal disturbance, tremor, weight gain, impotence, effects on behaviour and mood,
hepatic disturbance, rash and other skin reactions, bone marrow dyscrasia, leucopenia,
hyponatraemia, water retention, endocrine effects, effects on cardiac conduction, effects on
immunoglobulins

 DRUG: Clobazam
• MA: GABA A - receptor agonist
• DOSE:
• Initial: 10 mg/day; increase by increments of 10 mg/day; maintenance 10– 30 mg/day
• 3 – 12 years: initial dose 0.25 mg/kg per day; maintenance dose 0.25 – 1.5 mg/kg per day
• DOSING INTERVAL: Once or twice a day

• ORAL B.A: 90%
• METABOLISM: Hepatic demethylation and hydroxylation and then conjugation
• HALF LIFE: 10– 30 h
 DRUG:
• Adjunctive and monotherapy in epilepsy. Also for intermittent therapy, one – off
prophylactic therapy. Adults and children
• SIDE EFFECTS:
• Drowsiness, sedation, asthenia, ataxia, weakness and hypotonia, diplopia, mood and
behavioural change, dependency, withdrawal symptoms

 DRUG: Clonazepam
• MA: GABA A - receptor agonist
• DOSE:
• Initial: 0.25 mg at night; increments of 0.25 – 0.5 mg/day every 2 weeks
• Maintenance: 0.5– 4 mg/day
• Initial: < 1 year: 0.25 mg/day
• 1– 5 years: 0.25 mg/day
• 5– 12 years: 0.25 mg/day
• Maintenance:
• < 1 year: 1 mg/day
• 1– 5 years: 1– 2 mg/day
• 5– 12 years: 1– 3 mg/day

• ORAL B.A: 80%
• METABOLISM: Hepatic reduction, hydroxylation and acetylation
 DRUG: Clonazepam
• Monotherapy and adjunctive therapy in partial and generalized seizures (including absence
and myoclonus) and also the Lennox – Gastaut syndrome, neonatal seizures, infantile
spasms and status epilepticus. Adults and children
• SIDE EFFECTS:
• Drowsiness, sedation, asthenia, ataxia, weakness and hypotonia, diplopia, mood and
behavioural change, drooling and hypersalivation, dependency, withdrawal symptoms

 DRUG: Lacosamide
• DOSE:
• Initial: 50 mg/day; increased by increments of 50 mg/day every 2 weeks
• Maintenance: 200– 400 mg/day
• DOSING INTERVAL: Twice a day

• ORAL B.A: < 100%
• TIME TO PEAK: 0.5 – 4 h
• METABOLISM: O - Desmethylation
• DOSE AFFECTED BY : No
 DRUG: Lacosamide
• Adjunctive therapy of partial - onset seizures. Adults only
• SIDE EFFECTS:
• Dizziness, headache, nausea, diplopia ataxia, memory impairment, somnolence, tremor,
vertigo, constipation, pruritus, asthenia, fatigue

 DRUG: Lamotrigine
• DOSE:
• Initial: 12.5– 25 mg/day; increased by increments of 50– 100 mg/day every 2 weeks
• Depends on co - medication

• ORAL B.A: < 100%
• METABOLISM: Hepatic glucuronidation without phase 1 reaction
• DOSE AFFECTED BY : Avoid in hepatic disease
 DRUG: Lamotrigine
• Adjunctive or monotherapy of partial seizures and generalized seizures, and seizures
associated with the Lennox – Gastaut syndrome in those aged ≥ 13 years. Adjunctive
therapy of partial seizures and generalized seizures, and monotherapy of typical absence
seizures in those aged 2 – 12 years
• SIDE EFFECTS:
• Rash (sometimes severe), blood dyscrasia, headache, ataxia, asthenia, diplopia, nausea,
vomiting, dizziness, somnolence, insomnia, depression, behavioral effects, psychosis,
tremor

 DRUG: Levetiracetam
• MA: Action via binding to SV2A synaptic vesicle protein
• DOSE:
• Initial: 125– 250 mg/day; increased by increments of 250– 500 mg/day every 2 weeks
• Initial: 10 – 20 mg/kg per day, increased by increments of 10 – 20 mg/kg per day every 2
weeks
• Maintenance 20 – 60 mg/kg per day

• ORAL B.A: < 100%
• METABOLISM: Hydrolysis in many body tissues.
• DOSE AFFECTED BY : Renal disease
 DRUG: Levetiracetam
• Adjunctive therapy in partial - onset seizures in adults and children aged > 1 month, and in
myoclonic and tonic – clonic seizures in juvenile myoclonic epilepsy, age ≥ 12 years.
• Monotherapy in partial seizures with or without secondarily generalized seizures in patients
aged ≥ 16 years
• SIDE EFFECTS:
• Somnolence, asthenia, infection, dizziness, headache, irritability, aggression, behavioural
• and mood changes, emotional lability, depersonalization, psychosis, nervousness, seizure
• exacerbation, rhinitis, cough, vomiting

 DRUG:
• MA: Inhibition of sodium channel conductance.
• DOSE:
• Initial: 300 mg/day; increased by increments of 300 mg/day every 2 weeks
• Initial: 4 – 5 mg/kg per day, increased by 5 mg/kg per day increments weekly or 2 weekly
as required
• Maintenance: 20 – 45 mg/kg per day (maximum 60 mg/kg per day)

• ORAL B.A: < 100%
• METABOLISM: Hepatic reduction to MHD, then conjugation
• DOSE AFFECTED BY : Severe renal disease
 DRUG:
• Monotherapy and adjunctive therapy in partial - onset seizures and generalized tonic –
clonic seizures. Adults and children ≥ 6 years
• SIDE EFFECTS:
• Somnolence, headache, dizziness, diplopia, ataxia, rash, hyponatraemia, weight gain,
alopecia, nausea, gastrointestinal disturbance

 DRUG: Phenobarbital
• MA: GABA A - receptor agonist. Also depresses glutamate excitability, and affects sodium,
• potassium and calcium conductance
• DOSE:
• Initial: 30 mg/day; increased by increments of 15 – 30 mg every 2 weeks
• Maintenance: 30– 120 mg/day (maximum 180 mg/day)
• Neonates: 3 – 4 mg/day; initially 1 – 2 mg/day
• Children 1month – 12 years: initially 1 – 1.5 mg/kg per day, increased by 2 mg/kg per day
as required
• Usual maintenance dose 3– 8 mg/kg per day
• Children ≥ 12 years 30 – 180 mg/day; initially 15 mg/day
• DOSING INTERVAL: Once a day

• ORAL B.A: 80 – 100%
• METABOLISM: Hepatic oxidation, glucosidation and hydroxylation, then conjugation
• DOSE AFFECTED BY : Severe hepatic and renal disease
 DRUG: Phenobarbital
• Monotherapy and adjunctive therapy in partial or generalized seizures (including absence
and myoclonus) in adults and children. Also status epilepticus, the Lennox – Gastaut
syndrome, other childhood epilepsy syndromes, febrile convulsions, neonatal seizures
• SIDE EFFECTS:
• Sedation, ataxia, dizziness, insomnia, hyperkinesis (children), dysarthria, mood changes
(especially depression), behaviour change, aggressiveness, cognitive dysfunction,
impotence, reduced libido, folate defi ciency and megaloblastic anaemia, vitamin K and
vitamin D defi ciency, osteomalacia, Dupuytren contracture, frozen shoulder, shoulder –
hand syndrome, connective tissue abnormalities, rash. Risk of dependency. Potential for
abuse

 DRUG: Phenytoin
• DOSE:
• Initial: 200 mg at night; increased by 25 – 100 mg/day increments every 2 weeks.
• Child: 1 month to < 12 years: initially 1.5 – 2.5 mg/kg per day, usual maximum
• 7.5 mg/kg per day
• 12 – 18 years 75 – 150 mg/day; initially 75 mg/day. Usual maximum 300 mg/day

• ORAL B.A: 95%
• METABOLISM: Hepatic oxidation, glucosidation, hydroxylation, and then glucuronidation
 DRUG: Phenytoin
• Monotherapy and adjunctive therapy in partial - onset seizures and generalized tonic –
clonic seizures. Also status epilepticus. Adults and children
• SIDE EFFECTS:
• Ataxia, dizziness, lethargy, sedation, headaches, dyskinesia, acute encephalopathy
(phenytoin intoxication), hypersensitivity, rash, fever, blood dyscrasia, gingival hyperplasia,
folate defi ciency, megaloblastic anaemia, vitamin K defi ciency, decreased
immunoglobulins, mood changes, depression, coarsened facies, hirsutism, peripheral
neuropathy, osteomalacia and osteoporosis, hypocalcaemia, hormonal dysfunction, loss of
libido, hepatitis, coagulation defects

 DRUG: Topiramate
• MA: Inhibition of sodium channel conductance, potentiation of GABA - mediated inhibition
at the GABA A receptor, reduction of AMPA receptor activity, inhibition of high - voltage
calcium channels, carbonic anhydrase activity
• DOSE:
• Initial: 25– 50 mg/day; increased by 25– 50 mg/day increments every 2 weeks.
• Initial: 0.5 – 1 mg/kg per day
• Maintenance: 5 – 9 mg/kg per day

• ORAL B.A: < 100%
• METABOLISM: In monotherapy, most of the drug is excreted without metabolism
• DOSE AFFECTED BY : Renal disease
 DRUG: Topiramate
• Adjunctive therapy for partial - onset seizures and for the Lennox – Gastaut syndrome, ≥ 2
years of age. Monotherapy for partial - onset and generalized seizures, ≥ 6 years of age
• SIDE EFFECTS:
• Dizziness, ataxia, headache, paraesthesia, tremor, somnolence, cognitive dysfunction,
confusion, agitation, amnesia, depression, emotional lability, nausea, diarrhoea, diplopia,
weight loss , Renal calculi

 DRUG: Valproate
• MA: Effects on GABA and glutaminergic activity, calcium (T) conductance and potassium
• conductance
• DOSE:
• Initial: 200– 500 mg/day; increasing by 200– 500 mg increments every 2 weeks
• Neonates: initial and maintenance: 20 mg/kg
• Children 1 month to 12 years: initial: 10 – 15 mg/kg; maintenance 25 – 30 mg/kg (up to
• 60 mg/kg in infantile spasms)
• DOSING INTERVAL: 2 – 3 times/day

• ORAL B.A: < 100%
• METABOLISM: Hepatic oxidation, epoxidation, reduction and glucuronidation
• DOSE AFFECTED BY : Avoid in hepatic disease
 DRUG: Valproate
• Monotherapy and adjunctive therapy in partial - onset and generalized seizures, including
myoclonus and absence, and for the seizures associated with the Lennox – Gastaut
syndrome. Idiopathic generalized epilepsy, febrile convulsions, other childhood epilepsy
syndromes. Adults and children
• SIDE EFFECTS:
• Nausea, vomiting, hyperammonaemia and other metabolic effects, endocrine effects,
severe hepatic toxicity, pancreatitis, drowsiness, cognitive disturbance, aggressiveness,
tremor, weakness, encephalopathy, thrombocytopenia, neutropenia, aplastic anemia, hair
thinning and hair loss, weight gain, polycystic ovarian syndrome

THANK YOU
• ganeshgoudam4@gmail.com
• 9380906082

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