NHS Dudley Health Economy Medicines Formulary
Home > 4 Central nervous system > 4.8 Antiepileptic drugs > 4.8.1 Control of the epilepsies

4.8.1 Control of the epilepsies

NICE clinical guideline 137 - Epilepsy

General guidance     

  • The objective of the treatment of epilepsy is to prevent the occurrence of seizures.
  • The dosage of anti-epileptic therapy needs careful adjustment in order to control seizures whilst minimising adverse effects. Treatment should commence with low doses which are gradually increased until seizures are controlled or adverse effects occur.
  • The frequency of administration varies but should be kept as low as possible to encourage better patient compliance. Most agent may be given twice daily, although with larger doses some drugs require more frequent dosing in order to minimise adverse effects associated with high peak plasma concentrations.
  • Therapy with two or more antiepileptic drugs concurrently should preferably only be used when monotherapy with several alternative drugs has proven ineffective.
  • Interactions between antiepileptics are complex and may enhance toxicity and/or decrease seizure control. Great care is therefore necessary.
  • The changeover from one antiepileptic drug regimen to another should be made cautiously, withdrawing the first drug only when the new regimen has been largely established.
  • The decision to withdraw all antiepileptics from a seizure-free patient, and its timing, is often difficult and may depend on individual patient factors. Even in patients who have been seizure free for several years, there is a significant risk of seizure recurrence on drug withdrawal.
  • Abrupt withdrawal of antiepileptics, particularly the barbiturates and benzodiazepines, should be avoided, as this may precipitate severe rebound seizures. Reduction in dosage should be carried out in stages and, in the case of the barbiturates, the withdrawal process may take months.
  • Antiepileptic drug therapy is associated with an increased risk of teratogencity in addition to loss of seizure control due to altered plasma drug concentrations, therefore women should be advised to contact their doctor if considering pregnancy or if they are pregnant.

Recommended drugs

See Dudley Epilepsy Formulary for treatment by seizure  type, first line treatment, adjuvant treatment, which medicines to avoid by seizure type and statement on brand vs generic prescribing (See BNF for doses)

Brivaracetam 
Carbamazepine
Clobazam
Clonazepam
Eslicarbamazepine
Ethosuximide
Gabapentin
Lacosamide
Lamotrigine
Levetiracetam
Oxcarbazepine
Phenobarbital
Pregabalin
Primidone
Sodium valproate
Tiagabine
Topiramate
Vigabatrin
Zonisamide

Brivaracetam is approved for inclusion in the formulary as per SMC guidance – adjunctive therapy for epilepsy without secondary generalisation.  ACE requested that the neurology specialists return in one year (September 2018) with 1 year data to support a review of the formulary position.  LN to provide hospital prescribing data in 12 months, Primary Care to return with ePACT data covering the same time period.

If considering benzodiazipines, please see the prescribing guidelines for Benzodiazepines in Adults

Please also see NICE guidance on Retigabine


Drug Traffic Light Key:

Green – On Formulary

Amber – Restricted use, see local guidelines      

Purple – Specialist use/initiation

Red – Non Formulary

 

Relative Costs Key (where indicated):

£££££ - high

£££ - moderate

£ - low

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