Individual Medications

A prescription specifies the name of the drug, the number of milligrams in each pill or liquid, the number of doses and amounts to be given each time of day, the number of pills to be dispensed, and the number of automatic refills allowed. Prescriptions also specify whether brand name drugs or cheaper generic drugs should be used.

Recommendations listed below are solely the opinions of the author, Robert Fisher, MD. Not all medications have an FDA (Food and Drug Administration) indication for the regimen given. A reader with epilepsy should use the "summary information" as a reference source. 

Please DO NOT change your medication because of information presented here. Rather, use it as a starting point for discussion with your physician.


Dosages

Are given, except where otherwise specified, as total daily milligrams.  For example, Lamictal dose may be listed as "400 mg per day in 2 divided doses," meaning 200 mg in the morning and 200 mg in the evening.

Some drugs can be started more quickly than can others.  Dilantin, Neurontin, phenobarbital, Keppra, and benzodiazepines can be initiated rapidly. These drugs therefore go to work quickly against the seizures. 

Tegretol, Trileptal, Depakote, Lamictal, Topamax, Gabitril, and Zonegran must be titrated up in dose over weeks to months, in order to allow the system to adjust and minimize side effects.  Such a slow titration is a disadvantage, because it delays the onset of seizure control. 

The discussion of individual drugs provides typical initiation schedules for drugs. However, the schedules are general guidelines.  A patient who is very sensitive to side effects of medicines, or who already is carrying the burden of several other seizure medicines, might require a slower titration schedule. 

In contrast, a patient who is having severe seizures might risk a fast initiation schedule in order to control seizures sooner.  The treating physician should individualize the initiation schedule. Similar principles apply to the final dosage level, which also must be individualized.

 

Metabolism

Metabolism (usually liver, kidney, or both) is listed in case you have liver or kidney insufficiency.  In that case, dosing might require special adjustment. The cryptic letters and numbers in the metabolism section, such as "CYP 3A4," specify the specific chemical system responsible for metabolizing the drug. Most readers can ignore this information, but it is useful if a question arises about a possible interaction with a medicine not listed. If that medicine also is metabolized by the same liver system, then there is a higher likelihood of a drug interaction with the seizure medicine.

Half-life

The half-life of a drug measures how long, on the average, it takes to clear half of the drug from the blood. The longer the half-life, the longer the drug sticks around.  Drugs with long half-lives, such as phenobarbital or brand-name Dilantin, only need to be taken once a day. Drugs with short half-lives, such as Neurontin, need to be taken 3 or 4 times per day in order to avoid excessive fluctuation of blood levels.


 

Plasma (or serum)

Concentrations of anti-epileptic drugs show how much drug is maintained in the blood, and therefore presumably in the brain. The drug levels should ideally be within the therapeutic range.  However, these ranges are guidelines, not mandates.  If a patient is seizure-free and non-toxic, than checking a drug level will not likely contribute to management. Ranges are averages, and they originally were calibrated for patients on monotherapy. They may not apply to an individual case. Measurement of levels is most useful for phenytoin (Dilantin), whose levels can swing low to high very easily, somewhat useful for carbamazepine (Tegretol), phenobarbital, and valproate (Depakote).  Levels tend not to be useful for the newer medicines, which have a very broad therapeutic range.


 

Drug interactions

Are listed for the generic forms of drug, and are divided into those that affect the seizure medication (increased and decreased effect), and those for which the seizure medication affects another drug. Look up the generic drugs you are on and see if any are in the interaction list.  If they are, discuss any problems with your doctor.  Not all drug interactions are listed, so when in doubt check with your doctor or pharmacist.  Some drugs pairs have more than one type of interaction, causing increased effects in some people and decreased effects in others.

 

Side Effects

A side effects list cannot be comprehensive, so you'll see a list of the most common and the most serious, along with a few others. Do not be paralyzed by the list of side effects! Like the "Ghost of Future Christmas," it is what might be, not what will be. Some side effects, for example dizziness or fatigue, are so common as to be hard to attribute to a medicine, unless they start and stop with changes in that medicine.

The package insert about a drug and the Physician's Desk Reference (PDR) are required to list all reported side effects of a drug during clinical trials, some of which may be due to other factors than the drug.  Many side effects seen in seizure clinics are due to combination toxicity from more than one medicine. Discuss possible side effects of seizure medicines with your medical team.

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