4.8.1 Control of epilepsy

Pharmacological treatment of focal (partial) seizures, with or without secondary generalization
ChoiceDrugDosage
1st choiceCarbamazepine m/r tablets 200mg, 400mg
Carbamazepine tablets 100mg, 200mg, 400mg; liquid 100mg/5ml
Carbamazepine suppositories 125mg, 250mg
Dose:
See BNF
Or
Lamotrigine tablets 25mg, 50mg, 100mg, 200mgDose:
See BNF
2nd choiceLevetiracetam tablets f/c 250mg, 500mg, 750mg, 1g; oral solution 100mg/ml; Dose:
See BNF
Or
Oxcarbazepine tablets 150mg, 300mg, 600mgDose:
See BNF
Or

Sodium valproate tablets e/c 200mg, 500mg; m/r 200mg, 300mg, 500mg; oral solution 200mg/5ml;

[NB Sodium valproate is contraindicated in women and girls of childbearing potential unless conditions of Pregnancy Prevention Programme are met – see MHRA (link to https://www.gov.uk/drug-safety-update/valproate-medicines-epilim-depakote-contraindicated-in-women-and-girls-of-childbearing-potential-unless-conditions-of-pregnancy-prevention-programme-are-met]

Dose:
See BNF
Pharmacological treatment of generalised (primary generalized tonic-clonic, absence, myoclonic, tonic, clonic, atonic) and unclassified seizures
ChoiceDrugDosage
1st choices

Sodium valproate tablets e/c 200mg, 500mg; m/r 200mg, 300mg, 500mg; oral solution 200mg/5ml; injection 100mg/ml; intravenous injection 400mg (powder and solvent for solution for injection vials)

[NB Sodium valproate is contraindicated in women and girls of childbearing potential unless conditions of Pregnancy Prevention Programme are met – see MHRA (link to https://www.gov.uk/drug-safety-update/valproate-medicines-epilim-depakote-contraindicated-in-women-and-girls-of-childbearing-potential-unless-conditions-of-pregnancy-prevention-programme-are-met]

Dose:
See BNF
Or
Lamotrigine tablets 25mg, 50mg, 100mg, 200mgDose:
See BNF
2nd choicesLevetiracetam tablets f/c 250mg, 500mg, 750mg, 1g; oral solution 100mg/ml; concentrate for intravenous infusion 100mg/mlDose:
See BNF
Or
Topiramate tablets 25mg, 50mg, 100mg, 200mgDose:
See BNF

Prescribing Notes

(Click here for ‘Initiation of pharmacological treatment’)

(Click here for ‘Adjunctive pharmacological treatment’)

General Information

  • Refer to NICE CG137 ‘The epilepsies: diagnosis and management of the epilepsies in adults and children in primary and secondary care’ January 2012.
  • The AED treatment strategy should be individualised according to the seizure type, epilepsy syndrome, co-medication and co-morbidity, the young person or adult’s lifestyle, and the preferences of the person and their family and/or carers as appropriate.
  • All antiepileptic drugs carry a risk of teratogenicity.
  • Valproate medicines (Epilim▼, Depakote ▼) are contraindicated in women and girls of childbearing potential unless conditions of Pregnancy Prevention Programme are met. For further information see MHRA Drug Safety Update April 2018.
  • If using carbamazepine, offer controlled-release carbamazepine preparations.
  • The dose of antiepileptic drug may need to be adjusted in women who commence or stop oral contraceptives, or who become pregnant while taking antiepileptic drugs; see SPCs for further information.
  • Liquid formulations and dispersible or chewable tablets are more expensive than standard tablets. Standard tablet formulations (m/r or e/c included) should be prescribed where possible.
  • Many antiepileptic drugs are hepatic enzyme-inducing agents, e.g. carbamazepine, phenytoin, phenobarbital, oxcarbazepine, eslicarbazepine acetate and topiramate.
    • Antiepileptic drugs which induce hepatic enzymes may impair the efficacy of oral contraceptives; see BNF for details.
    • Sudden withdrawal of these drugs may decrease the rate at which warfarin is metabolized and put a patient taking a combination of these drugs at an increased risk of bleeding.

Initiation of pharmacological treatment

  • AED therapy should only be started once the diagnosis of epilepsy is confirmed, except in exceptional circumstances.
  • Whenever possible, AED therapy should be initiated in adults on the recommendation of a specialist. Treatment with AED therapy is generally recommended after a second epileptic seizure. If a second fit occurs before the patient is seen by a specialist then start first choice agent. Phone for specialist advice if required.
  • Routine plasma drug level monitoring is generally unnecessary unless side-effects are a problem, non-compliance is suspected, or phenobarbital or phenytoin are administered. Monitoring is seldom of value for patients on sodium valproate.
  • Abnormal blood parameters occur with a number of AEDs. Routine bloods should be checked at baseline, after initiation of a new AED and periodically thereafter (every 1-2 years).
  • Gradual withdrawal of antiepileptic drugs can be considered with caution, for some patients, after 2 years free of seizures but note implications for driving. Specialist advice should always be sought to estimate the individual risk of seizure recurrence on withdrawal of AED treatment.

Adjunctive pharmacological treatment

  • Offer adjunctive treatment to young people and adults with epilepsy if first-line treatments are ineffective or not tolerated.
  • If adjunctive treatment is ineffective or not tolerated, discuss with, or refer to a tertiary epilepsy specialist.
  • AED options by seizure type are listed in Appendix E of the NICE Guideline 137.