Anticonvulsants by Seizure Type (Chart)

Seizure Type	Age	Commonly Used	Alternatives
Primarily generalized tonic-clonic seizures	1-12 mon	Carbamazepine, Phenytoin, Phenobarbital	Valproate
Primarily generalized tonic-clonic seizures	1-6 yr	Carbamazepine, Phenytoin, Phenobarbital	Valproate
Primarily generalized tonic-clonic seizures	6-11 yr	Carbamazepine	Valproate, Phenytoin, Phenobarbital, Lamotrigine*
Primarily generalized tonic-clonic seizures with absence or with myoclonic seizures	1 mon -18 yr	Valproate	Phenytoin**, Phenobarbital**, Carbamazepine**
Absence seizures	Any age	Ethosuximide	Valproate, Clonazepam, Dimox, Lamotrigine*
Myoclonic seizures	Any age	Valproate, Clonazepam	Phenytoin*, Phenobarbital*
Tonic and atonic seizures	Any age	Valproate	Phenytoin*, Clonazepam, Phenobarbital*
Partial seizures	1-12 mon	Phenobarbital	Carbamazepine, Phenytoin
Partial seizures	1-6 yr	Carbamazepine	Phenytoin, Phenobarbital, Valproate*, Lamotrigine*, Gabapentin
Partial seizures	6-18 yr	Carbamazepine	Lamotrigine, Phenytoin, Phenobarbital, Tiagabine, Topriamate, Valproate*
Infantile spasms		Corticotropin (ACTH)	Prednisone*, Valproate*, Clonazepam*, Diazepam*

*Not FDA approved for this indication

**Phenytoin, phenobarbital, carbamazepine will not treat absence seizures. Addition of another anticonvulsant (ie, ethosuximide) would be needed.

Carbamazepine

Nutrients Depleted:

Biotin, Folic Acid, Vitamin D

U.S. Brand Names:

Carbatrol®; Epitol®; Tegretol®; Tegretol®-XR

Use:

Prophylaxis of generalized tonic-clonic, partial (especially complex partial), and mixed partial or generalized seizure disorder; pain relief or trigeminal neuraliga.

Pregnancy Risk Factor and Implications:

C; Enters breast milk/compatible.

Contraindications:

Hypersensitivity to carbamazepine or any component; may have cross-sensitivity with tricyclic antidepressants; should not be used in any patient with bone marrow suppression. MAO inhibitor use; the oral suspension should not be administered simultaneously with other liquid medicinal agents or diluents.

Dietary Considerations:

Food: Drug may cause GI upset, take with large amounts of water or food to decrease GI upset. May need to split doses to avoid GI upset.
Sodium: SIADH and water intoxication; monitor fluid status,; may need to restrict fluid.

Warnings/Precautions:

MAO inhibitors should be discontinued for a minimum of 14 days before carbamazepine is begun; administer with caution to patients with history of cardiac damage of hepatic disease; potentially fatal blood cell abnormalities have been reported following treatment; early detection of hematologic change is important; advise patients of early signs and symptoms including fever, sore throat, mouth ulcers, infections, easy bruising, petechial or purpuric hemorrhage; carbamazepine is not effective in absence, myoclonic or akinetic seizures; exacerbation of certain seizure types have been seen after initiation of carbamazepine therapy in children with mixed seizure disorders. Elderly may have increased risk of SAIDH-like syndrome.

Adverse Reactions:

Dermatologic: Rash; but does not necessarily mean the drug should not be stopped

At least 10% experienced:

• Central nervous system: Sedation, dizziness, fatigue, ataxia, confusion
  
• Gastrointestinal: Nausea, vomiting
  
• Ocular: Blurred vision, nystagmus
  
  

1% to 10% experienced:

• Dermatologic: Stevens-Johnson syndrome, toxic epidermal necrolysis
  
• Endocrine & metabolic: Hyponatremia, SIADH
  
• Gastrointestinal: Diarrhea
  
• Miscellaneous: Diaphoresis
  

Less than 1% experienced:

Edema, congestive heart failure, syncope, bradycardia, hypertension or hypotension, A-V block, arrhythmias, slurred speech, mental depression, hypocalcemia, hyponatremia, urinary retention, sexual problems in males, neutropenia (can be transient), aplastic anemia, agranulocytosis, eosinophilia, leukopenia, pancytopenia, thrombocytopenia, bone marrow suppression, hepatitis, peripheral neuritis, diplopia, swollen glands, hypersensitivity

Overdose/Toxicology:

Symptoms of overdose include dizziness, ataxia, drowsiness, nausea, vomiting, tremor, agitation, nystagmus, urinary retention, dysrhythmias, coma, seizures, twitches, respiratory depression, and neuromuscular disturbances. Activated charcoal is effective at binding certain chemicals and this is especially true for carbamazepine. Other treatment is supportive and symptomatic.

Phenobarbital

Nutrients Depleted:

Calcium, Folic Acid, Vitamin D, Vitamin K

U.S. Brand Names:

Barbita®; Luminal®; Solfoton®

Use:

Management of generalized tonic-clonic (grand mal) and partial seizures; neonatal seizures; febrile seizures in children; sedation; may also be used for prevention and treatment of neonatal hyperbilirubemia and lowering of bilirubin in chronic cholestasis.

Pregnancy Risk Factor and Implications:

D; Enter breast milk/not recommended.

Contraindications:

Hypersensitivity to phenobarbital or any component; pre-existing CNS depression, severe uncontrolled pain, porphyria, severe respiratory disease with dyspnea or obstruction.

Dietary Considerations:

Alcohol: Additive CNS effect, avoid use
Protein-deficient diets: Increases duration of action of barbiturates. Should not restrict or delete protein from diet unless discussed with physician. Be consistent with protein intake during therapy with barbiturates.
Fresh fruits containing vitamin C: Displaces drug from binding sites, resulting in increased urinary excretion of barbiturate. Educate patients regarding the potential for decreased anticonvulsant effect of barbiturates with consumption of foods high in vitamin C.
Vitamin D: Loss in vitamin D due to malabsorption; increase intake of foods rich in vitamin D. Supplementation of vitamin D may be necessary.

Warnings/Precautions:

Use with caution in patients with hypovelmic shock, congestive heart failure, hepatic impairment, respiratory dysfunction or depression, previous addiction to the sedative/hypnotic group, chronic or acute pain, renal dysfunction, and the elderly, due to its long half-life and risk of dependence, phenobarbital is nor recommended as a sedative in the elderly; tolerance or psychological and physical dependence may occur with prolonged use. Abrupt withdrawal in patients with epilepsy may precipitate status epilepticus.

Adverse Reactions:

At least 10% experienced:

• Cardiovascular: Hypotension, cardiac arrhythmias, bradycardia, arterial spasm
  
• Central nervous system: Dizziness, lightheadedness, "hangover" effect, drowsiness, lethargy, CNS excitation or depression, impaired judgement
  
• Local: Pain at injection site, thrombophlebitis with I.V. use
  
• Miscellaneous: Gangrene with inadvertent intra-arterial injection
  

1% to 10% experienced:

• Central nervous system: Confusion, mental depression, unusual excitement, nervousness, faint feeling, headache, insomnia, nightmares
  
• Gastrointestinal: Nausea, vomiting, constipation
  

Less than 1% experienced:

Hypotension, hallucinations, hypothermia, exfoliative dermatitis, Stevens-Johnson syndrome, rash, agranulocytosis, megaloblastic anemia, thrombocytopenia, laryngospasm, respiratory depression, apnea (especially with rapid I.V. use)

Overdose/Toxicology:

Symptoms of overdose include unsteady gait, slurred speech, confusion, jaundice, hypothermia, hypotension, respiratory depression, and coma. Treatment is symptom directed and supportive.

Valproate

Nutrients Depleted:

Carnitine, Folic Acid

U.S. Brand Names:

Depacon®; Depakene®; Depakote®

Use:

Management of simple and complex absence seizures; mixed seizure types; myoclonic and generalized tonic-clonic (grand mal) seizures; may be effective in partial seizures, infantile spasms, bipolar disorder; prevention of migraine headaches

Pregnancy Risk Factor and Implications:

D; Enters breast milk/compatible

Contraindications:

Hypersensitivity to valproic acid or derivatives or any component; hepatic dysfunction.

Dietary Considerations:

Alcohol: Additive CNS depression, avoid or limit alcohol
Food:
Valproic acid may cause GI upset; take with large amount of water or food to decrease GI upset. May need to split doses to avoid GI upset. Food may delay but does not affect the extent of absorption. Coated particles of divalproex sodium may be mixed with semisolid food (eg, applesauce or pudding) in patients having difficulty swallowing; particles should be swallowed and not chewed.
Valproate sodium oral solution will generate valproic acid in carbonated beverages and may cause mouth and throat irritation; do not mix valproate sodium oral solution with carbonated beverages.
Milk: No effect on absorption; may take with milk.
Sodium: SAIDH and water intoxication; monitor fluid status. May need to restrict fluid.

Warnings/Precautions:

Hepatic failure resulting in fatalities has occurred in patients; children less than two years of age are at considerable risk; monitor patients closely for appearance of malaise, weakness, facial edema, anorexia, jaundice, and vomiting; may cause severe thrombosytopenia, bleeding; hepatoxicity has been reported after 3 days to 6 months of therapy; tremors may indicate overdoseage; use with caution in patients receiving other anticonvulsants.

Adverse Reactions:

1% to 10% experienced:

• Endocrine and metabolic: Change in menstrual cycle
  
• Gastrointestinal: Abdominal cramps, anorexia, diarrhea, nausea, vomiting, weight gain

Less than 1% experienced:

Drowsiness, ataxia, irritability, confusion, restlessness, hyperactivity, headache, malaise, alopecia, erythema multiforme, hyperammonemia, pancreatitis, thrombocytopenia, prolongation of bleeding time, transient increased liver enzymes, liver failure, tremor, nystagmus, spots before eyes

Overdose/Toxicology:

Symptoms of overdose include coma, deep sleep, motor restlessness, and visual hallucinations. Supportive treatment is necessary. Naloxone has been used to reverse CNS depressant effects, but may block the action of other anticonvulsants.

Corticotropin

U.S. Brand Names:

Acthar®

Use:

Used to treat infantile spasms.

Contraindications:

You will have an increased risk of infection while receiving corticotropin. Avoid people who have an infection. Do not receive any vaccinations as you may get a strong reaction. Avoid people who have recently taken oral polio vaccine. Tell your doctor if you are exposed to anyone with measles or chickenpox, or if you develop sores or blisters that do not heal properly. Corticotropin can interfere with certain lab tests and can cause false skin test results.

Warnings/Precautions:

Use caution and consult a doctor before using corticotropin if you have Cushing's syndrome, heart or circulation problems or blood clots, high blood pressure, high blood sodium levels, an infection (such as herpes), liver disease, low blood potassium level, osteoporosis, a peptic ulcer, recent surgery, scleroderma, an under-active thyroid, an unusual or allergic reaction to corticotropin, corticosteroids, pork proteins, or other medicines, foods, dyes, or preservatives, or if you are pregnant or trying to get pregnant or are breast-feeding.

Adverse Reactions:

Bloody or black, tarry stools, confusion, excitement, restlessness, a false sense of well-being, decreased or blurred vision, fever, sore throat, sneezing, cough, or other signs of infection, wounds that will not heal, frequent passing of urine, hallucinations, increased thirst, irregular heartbeat, mental depression, mood swings, mistaken feelings of self-importance or of being mistreated, menstrual problems, muscle cramps or weakness, nausea, vomiting, pain in hips, back, ribs, arms, shoulders, or legs, pain, redness, swelling, signs of allergy, or scarring at the injection site, rounding out of face, skin problems, acne, thin and shiny skin, stomach pain, swelling of feet or lower legs, unusual bruising, pinpoint red spots on the skin, unusual tiredness or weakness, weight gain, increased appetite, nervousness, restlessness, or difficultly sleeping, upset stomach, unusual increased growth of hair on the face or body.

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