Antiepileptic drugs (AEDs)
Antiepileptic drugs (AEDs)
Excerpt from the book Cafer's Pharmacology, available soon from Amazon
New AEDs are often initially approved as adjuncts for focal seizures (formerly called “partial” seizures) but are prescribed off-label for adjunctive treatment of bilateral tonic-clonic seizures (formerly “primary generalized” seizures) and/or as monotherapy. GABA is the brain’s principal inhibitory neurotransmitter. AEDs with “gab” in their name are either structurally related to GABA and/or lead to GABA(A) receptor activation. Benzodiazepines (Chapter 4) may be used for epilepsy but are excluded from this list. Barbiturate monographs are in Chapter 3.
The monographs in this chapter are presented in order of mood stabilizers followed by the non-mood stabilizing AEDs in descending order of popularity in terms of number of prescriptions issued (Rx #).
Rx # | AED | ~ Cost | Psychiatric uses | Comments |
#1 | Gabapentin (NEURONTIN) | $10 | Pain, Anxiety, Alcoholism | #13 prescribed drug overall, usually for indications other than seizure disorder including neuropathic pain, fibromyalgia, and restless legs syndrome (RLS) |
#2 | Lamotrigine (LAMICTAL) | $10 | 1st line mood stabilizer | #70 overall. First line for bipolar maintenance and seizure disorders because of relative safety and benign side effect profile; Dose must be titrated over 5 weeks to avoid Stevens-Johnson Syndrome (SJS). Broad spectrum AED |
#3 | Pregabalin (LYRICA) | $100 | Anxiety | #83 overall; FDA-approved for focal seizures (adjunct), neuropathic pain, fibromyalgia, and post-herpetic neuralgia; Schedule V controlled substance (least restrictive) |
#4 | Topiramate (TOPAMAX) | $10 | Bipolar adjunct, weight loss, alcoholism, PTSD | #85 overall; Commonly causes (reversible) cognitive impairment at doses ≥ 200 mg; 15% risk of renal stones and possible metabolic acidosis, both attributable to alkalinization of urine |
#5 | Levetiracetam (KEPPRA) | $15 | No! | #89 overall; Broad spectrum AED, often first line for epilepsy; High incidence of irritability or mood disturbance, with potential for suicidal ideation, psychosis, and aggression |
#6 | Divalproex DR (DEPAKOTE) | $15 | 1st line mood stabilizer | #129 overall; The active drug is valproic acid (VPA). Potential for hepatotoxicity, hyperammonemic encephalopathy, tremor, and polycystic ovary syndrome (PCOS) |
#7 | Carbamazepine (TEGRETOL) | $40 | 2nd line mood stabilizer | #197 overall; Shredder CYP inDucer; Several serious health risks; Narrow spectrum AED |
#8 | Phenytoin (DILANTIN) | $25 | No | #201 overall; Shredder CYP inDucer that decreases blood levels of countless co-administered drugs; May cause gingival hypertrophy, coarse facial features, nystagmus, and cognitive impairment; Blood level monitoring is required; Narrow spectrum AED |
#9 | Primidone (MYSOLINE) | $15 | No | #237 overall; This barbiturate is metabolized to phenobarbital. Off-label treatment of tremor |
#10 | Oxcarbazepine (TRILEPTAL) | $20 | 2nd line mood stabilizer | #244 overall; Similar to carbamazepine with fewer risks and fewer interactions, but with greater risk of hyponatremia |
#11 | Phenobarbital (LUMINAL) | $30 | Alcohol detox | Barbiturate; The oldest AED still in use, discovered in 1912; For anxiety treatment, barbiturates have been replaced by the safer benzodiazepines |
#12 | Zonisamide (ZONEGRAN)  | $20 | Alcoholism, Nightmares | May cause irritability and cognitive impairment; Rare incidence of psychosis; May cause weight loss; Broad spectrum AED |
#13 | Lacosamide (VIMPAT) | $900 | No | Schedule V controlled substance (least restrictive) due to possible euphoria; Low incidence of mood problems; Narrow spectrum AED; Off patent in 2022 |
#14 | Ethosuximide (ZARONTIN) | $100 | No | Used only for petit mal (absence) seizures; Rarely associated with psychotic behavior; Risk of Stevens-Johnson syndrome (SJS) |
#15 | Eslicarbazepine (APTIOM) | $1000 | No (due to cost) | Prodrug of an active metabolite of oxcarbazepine; Risk of hyponatremia and Stevens-Johnson syndrome; Off patent in 2021; Potential mood stabilizer |
#16 | Rufinamide (BANZEL) | $1000 | Experimental for bipolar | Approved in 2008 as an adjunct for Lennox-Gastaut syndrome, but has potential as a broad spectrum AED; Can shorten QT interval |
#17 | Felbamate (FELBATOL) | $200 | No | Considered relatively benign in terms of psychiatric adverse effects. Broad spectrum AED; Small risk of aplastic anemia and hepatic failure |
#18 | Brivaracetam (BRIVIACT)  | $1000 | No! | Analog of levetiracetam; Less likely to cause disturbance of mood/behavior than levetiracetam; Schedule V controlled (least restrictive) |
#19 | Tiagabine (GABITRIL) | $100 | Mood stabilization and anxiety | GABA reuptake inhibitor; increases percentage of slow wave sleep; May induce seizures in patients without epilepsy |
#20 | Perampanel (FYCOMPA)  | $500 | No! | AMPA receptor antagonist; Black box warnings for severe psychiatric and behavioral reactions including hostility, aggression, and homicidal ideation - “Fight-compa”; Schedule III controlled |
#21 | Vigabatrin (SABRIL)  | $4000 | No! | Blocks breakdown of GABA; Restricted distribution due to risk of vision loss; May cause irritability, depression, and confusion; Narrow spectrum AED |
NEW 2020 | Cenobamate (XCOPRI) | $$$$ | No | Slow titration over 11 weeks is necessary to avoid Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS). |
Copyright 2020 Jason Cafer MD, CAFERMED LLC
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