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Benzodiazepines are used as adjunctive therapy with clobazam in the treatment of generalised tonic-clonic and refractory focal seizures while a specialist may prescribe them for refractory absence and myoclonic seizures. Buccal midazolam or rectal diazepam may be prescribed for children, young people and adults who have had a previous episode of prolonged or serial convulsive seizures.
Carbamazepine is initiated at a low dose and titrated upwards. It can be used for simple and complex focal seizures and is a treatment option for generalised tonic-clonic seizures. It can also be used as adjunctive treatment for focal seizures when monotherapy has been ineffective.
Ethosuximide is a firstline treatment option for absence seizures and may also be prescribed as adjunctive treatment when monotherapy is ineffective. It is also licensed for myoclonic seizures.
Gabapentin and pregabalin are used for the treatment of focal seizures and are not recommended if tonic, atonic, absence or myoclonic seizures are present.
Lamotrigine is used either as monotherapy or as an adjunct to treatment with other AEDs. When used in combination with sodium valproate, valproate increases the plasma lamotrigine concentration so care is needed in choosing the initial dose and on titration.
Levetiracetam is used for monotherapy and adjunctive treatment of focal seizures and for adjunctive treatment of myoclonic seizures and primary generalised tonic-clonic seizures.
Oxcarbazepine is licensed as monotherapy or adjunctive therapy for the treatment of focal seizures.
Phenobarbital can be used for tonic-clonic and focal seizures and may be tried for atypical absence, atonic and tonic seizures. Phenobarbital can cause sedation and rebound seizures on withdrawal.
Phenytoin is licensed for tonic-clonic and focal seizures but may exacerbate absence or myoclonic seizures so should be avoided if these seizures are present. Small dosage increases can produce large increases in plasma concentration with acute toxic side effects in some patients so monitoring of plasma-drug concentration is needed.
Topiramate has risks related to its use during pregnancy so effective contraception is needed in female patients.
Sodium valproate is the drug of choice in generalised and unclassifiable types of epilepsy. A widespread metabolic effect occurs with sodium valproate so liver function tests and a full blood count are essential. It has a high teratogenic potential and must not be used in females of childbearing potential unless the conditions of the pregnancy prevention programme are met.
Antiepileptic drugs (AEDs)
