netFormulary Tayside Area Formulary NHS
 
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 Formulary Chapter 4: Central nervous system - Full Chapter
04.08  Expand sub section  Antiepileptics
04.08.01  Expand sub section  Control of epilepsy
 note 
  • See BNF for significant interactions that occur with antiepileptics and between antiepileptics
  • See SIGN guideline 143 for information on epilepsy and women's health, including advice on antiepileptics in pregnancy or breastfeeding
  • See formulary section 09.01.02 for recommendations on folic acid dosage before and during pregnancy
  • SIGN guideline 143 has advice on interactions with contraceptives (including emergency contraception) and antiepileptics and includes the following recommendations:
    • To minimise the risk of contraceptive failure, a woman using any combined hormonal contraception, or a combined oral contraceptive pill, or a progesterone-only pill should be prescribed an antiepileptic drug that does not induce hepatic enzymes.
    • For women receiving hepatic enzyme-inducing antiepileptic drugs the depot (Depo-Provera®) or subcutaneous progesterone (Sayana Press®)levonorgestrel intrauterine system, or a non-hormonal intrauterine device may be used so contraceptive efficacy is maintained.
    • Although lamotrigine is not thought to affect the efficacy of combined hormonal contraceptives, lamotrigine concentrations are affected by combined hormonal contraceptives containing ethinyloestradiol/levonorgestrel, see SIGN guideline 143 and (Faculty of Sexual & Reproductive Healthcare) FSRH guidance for further advice.
    • See formulary section 07.03.05 for information on women with epilepsy who require emergency contraception while using enzyme-inducing drugs, or who have stopped taking these within the last 28 days.

The decision to start antiepileptic drugs should be made by the patient and an epilepsy specialist.

  • The clinical classification of epilepsy along with the adverse effect and interaction profiles for an individual patient are key in determining initial monotherapy.
  • The dose of each medication should be titrated slowly to the maximally tolerated dose or the maximum level as recommended in the BNF.
  • Effect may be monitored by patient-recorded seizure frequency.
  • Failure to respond to appropriate antiepileptic drugs should prompt a review of the diagnosis of epilepsy and adherence to medication.
  • Combination therapy should be considered when treatment with 2 first-line antiepileptic drugs has failed or when improved control occurs during the process of phased substitution.
  • The choice of drugs in combination should be matched to the patient's seizure type(s) and should, where possible, be limited to 2 or at most 3 antiepileptic drugs.

Treatment of focal seizures with or without secondary generalisation

  • First line treatments include: Lamotrigine, carbamazepine, or levetiracetam.
  • Other treatment options include: sodium valproate or topiramate.
  • There are also several options for adjunctive treatment (under specialist direction).

Treatment of generalised seizures

  • First line treatments include: Sodium valproate, lamotrigine, levetiracetam, or topiramate.
  • There are also several other options depending on seizure type/s (under specialist direction).

Adverse Effects

  • Patients should be warned of common potential adverse effects and given clear instructions to seek medical attention urgently for symptoms including rash, bruising or somnolence with vomiting especially in the first weeks of treatment.
  • Liver function and full blood count should not be monitored routinely.
04.08.01  Expand sub section  Carbamazepine and related antiepileptics
Carbamazepine

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Formulary
Amber
Tablets, M/R tablets, Liquid, Suppositories

  • Maintain patients on a specific manufacturer's product
  • Prescribe by brand name or generic drug name and name of manufacturer
  • Note: carbamazepine is a hepatic enzyme inducer, and reduces the effectiveness of hormonal contraceptives - see advice above
  • Treatment of focal epilepsy or as adjunctive treatment

    Link  MHRA alert: Antiepileptics - switching between brands (Nov 2013)
    Link  Tayside Neurology guidance - Carbamazepine
    Link  Tayside Therapeutic Drug Monitoring guidance
    Link  UKMI Q & A: Why is there a limit on the dose and duration of use for carbamazepine suppositories?  
  • Oxcarbazepine

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    Formulary
    Amber
    Tablets, Oral suspension

  • Note: oxcarbazepine a is hepatic enzyme inducer, and reduces the effectiveness of hormonal contraceptives - see advice above
  • Adjunctive treatment of focal epilepsy in patients who have been refractory to treatment.
  • Used in patients who have Carbamazepine intolerance [off-label].

    Link  Tayside Neurology guidance - Oxcarbazepine  
  • Eslicarbazepine

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    Formulary
    Amber
    Tablets

  • Note: eslicarbazepine is a hepatic enzyme inducer, and reduces the effectiveness of hormonal contraceptives - see advice above
  • FBC, LFTs, renal function required before initiating and after 6 months or earlier if clinically indicated
  • Adjunctive treatment of focal epilepsy
  • Restricted to patients with highly refractory epilepsy who have been heavily pre-treated and remain uncontrolled with existing anti-epileptic drugs
  • Used in patients who have Carbamazepine intolerance [off-label]


  • Link  Tayside Neurology guidance - Eslicarbazepine  
    04.08.01  Expand sub section  Ethosuximide
    Ethosuximide

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    Formulary
    Amber
    Capsules, Syrup

  • Generalised epilepsy second line monotherapy or adjunctive treatment
  • Option for absence seizures
     
  • 04.08.01  Expand sub section  Gabapentin and pregabalin to top
    04.08.01  Expand sub section  Lacosamide
    Lacosamide

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    Formulary
    Amber
    Tablets, Syrup

  • Adjunctive treatment of focal epilepsy in patients who have been refractory to treatment
  • Adjunctive treatment in refractory generalised epilepsy [off-label]

    Link  Tayside Neurology guidance - Lacosamide  
  • 04.08.01  Expand sub section  Lamotrigine
    Lamotrigine

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    Formulary
    Amber
    Tablets, Dispersible tablets

  • Note: Plasma half-life of lamotrigine doubled by sodium valproate, different dose tirations required with or without valproate

  • Note: lamotrigine concentrations are affected by combined hormonal contraceptives containing ethinyloestradiol/levonorgestrel, see SIGN guideline 143 and FSRH guidance below for further advice
  • First-line treatment of focal epilepsy or as adjunctive treatment
  • Generalised epilepsy or adjunctive treatment

    Link  FSRH guidance (Faculty of Sexual & Reproductive Healthcare)
    Link  SIGN guideline 143
    Link  Tayside Neurology guidance - Lamotrigine
    Link  UKMI Q&A: Lamotrigine is it safe to take while breastfeeding?  
  • 04.08.01  Expand sub section  Levetiracetam
    Levetiracetam
    (Oral)

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    Formulary
    Amber
    Tablets, Oral Solution

  • Treatment of focal epilepsy or as adjunctive treatment
  • Adjunctive treatment of generalised epilepsy

    Link  Tayside Neurology guidance - Levetiracetam  
  • 04.08.01  Expand sub section  Perampanel
    Perampanel

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    Formulary
    Amber
    Tablets

  • Note: at doses of 12mg per day or greater perampanel is a hepatic enzyme inducer, and reduces the effectiveness of hormonal contraceptives - see advice above
  • Second-line adjunctive treatment of focal epilepsy restricted to patients who have been refractory to treatment

    Link  SMC Advice
    Link  Tayside Neurology guidance - Perampanel  
  • 04.08.01  Expand sub section  Phenobarbital and other barbiturates to top
    Controlled Drug  Phenobarbital

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    Formulary
    Amber
    Tablets, Elixir, Injection

  • Note: phenobarbital is a hepatic enzyme inducer, and reduces the effectiveness of hormonal contraceptives - see advice above
  • Maintain patients on a specific manufacturer's product
  • Prescribe by generic drug name and name of manufacturer or prescribe by brand name
  • For patients with highly refractory epilepsy who have been heavily pre-treated and remain uncontrolled with existing anti-epileptic drugs.

    Link  MHRA alert: Antiepileptics - switching between brands (Nov 2013)
    Link  Tayside Therapeutic Drug Monitoring guidance  
  • 04.08.01  Expand sub section  Phenytoin
    Phenytoin
    (Oral)

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    Formulary
    Amber
    Tablets, Capsules, Suspension

  • Note: phenytoin is a hepatic enzyme inducer, and reduces the effectiveness of hormonal contraceptives - see advice above
  • Maintain patients on a specific manufacturer's product
  • Prescribe by generic drug name and name of manufacturer - 'Phenytoin Sodium Flynn Hard Capsules' are preferred, or prescribe by brand name
  • Care is needed when changing between formulations e.g. 100mg oral phenytoin (sodium) capsule is approximately equivalent to the phenytoin (base) syrup 90mg in 15mL
  • Adjunctive treatment in patients with focal epilepsy
  • Restricted to patients with highly refractory epilepsy

    Link  Phenytoin Prescribing and Monitoring Guideline
    Link  Tayside Therapeutic Drug Monitoring guidance
    Link  MHRA alert: Antiepileptics - switching between brands (Nov 2013)  
  • 04.08.01  Expand sub section  Retigabine
    04.08.01  Expand sub section  Rufinamide
    04.08.01  Expand sub section  Brivaracetam
    Brivaracetam

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    Formulary
    Amber
    Tablets, Oral Solution, Solution for Injection/Infusion

  • Second-line adjunctive treatment of focal epilepsy in patients from 16 years of age who have been refractory to treatment e.g. where other treatment options such as levetiracetam have failed or not been tolerated
  • Brivaracetam solution for injection/infusion is an alternative for patients when oral administration is temporarily not feasible
  • Intake of alcohol is not recommended with brivaracetam - see SPC for further information
     
  • 04.08.01  Expand sub section  Tiagabine to top
    Tiagabine

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    Formulary
    Amber
    Tablets

  • Doses differ with or without enzyme-inducing drugs
  • Adjunctive therapy in patients with focal epilepsy
  • Restricted to patients with highly refractory epilepsy who have been heavily pre-treated and remain uncontrolled with existing anti-epileptic drugs


  • Link  Tayside Neurology guidance - Tiagabine  
    04.08.01  Expand sub section  Topiramate
    Topiramate

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    Formulary
    Amber
    Tablets

  • Note: at doses of 200mg per day of greater topiramate is a hepatic enzyme inducer, and reduces the effectiveness of hormonal contraceptives - see advice above
  • See BNF for advice on nephrolithiasis and acute myopia with secondary angle-closure glaucoma
  • Focal epilepsy or as adjunctive treatment
  • Generalised epilepsy or as adjunctive treatment

    Link  Tayside Neurology guidance - Topiramate  
  • 04.08.01  Expand sub section  Valproate
    Sodium Valproate
    (Oral)

    View adult BNF  View SPC online  Track Changes
    Formulary
    Amber
    E/C tablets, Crushable tablets, Liquid, M/R tablets

  • See BNF for advice on liver dysfunction, blood or hepatic disorders, and pancreatitis
  • Should not be used during pregnancy and in women of childbearing potential unless clearly necessary - in line with MHRA advice below
  • Generalised epilepsy or adjunctive treatment

    Link  Tayside Neurology guidance - Sodium Valproate
    Link  Tayside Prescriber Issue No 142 - Valproate and Risk of Abnormal Pregnancy Outcomes, June 2016  
  • 04.08.01  Expand sub section  Vigabatrin
    Vigabatrin

    View adult BNF  View SPC online  Track Changes
    Formulary
    Amber
    Tablets, Granules

  • Adjunctive therapy in patients with focal epilepsy
  • Restricted to patients with highly refractory epilepsy who have been heavily pre-treated and remain uncontrolled with existing anti-epileptic drugs
  • See BNF for advice on visual field defects
     
  • 04.08.01  Expand sub section  Zonisamide
    Zonisamide

    View adult BNF  View SPC online  Track Changes
    Formulary
    Amber
    Capsules

  • Caution risk of nephrolithiasis - ensure adequate hydration - combined use with topiramate increases this risk
  • Adjunctive therapy in patients with focal epilepsy, (with or without secondary generalisation)
  • Refractory generalised epilepsy [off-label]
  • Not recommended by SMC as monotherapy

    Link  Tayside Neurology guidance - Zonisamide  
  • 04.08.01  Expand sub section  Benzodiazepines to top
    Clobazam

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    Formulary
    Amber
    Tablets, Oral suspension

  • Adjunct in epilepsy for chronic therapy or acute deterioration
     
  • 04.08.02  Expand sub section  Drugs used in status epilepticus
     note  Medicines within this section relate to the management of status epilepticus in adults.

    Management of prolonged seizures including status epilepticus:

    Refer to the Protocol for management of status epilepticus in General Practice in adults (for patients in the community) or the Protocol for management of in-patient status epilepticus in adults (for patients in hospital including convulsive and non-convulsive status epilepticus).

    Controlled Drug  Midazolam (Epistatus)
    (Status epilepticus)

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    Formulary
    Green
    Buccal liquid 10mg/mL in 5mL (unlicensed)

  • FIRST CHOICE Status epilepticus in the community
  • Status epilepticus in hospital if IV lorazepam not available or IV access not possible
  • Acute seizure management in palliative care

  • SPC link is not applicable for this product

    Link  NHS Scotland Palliatve care guidelines - Seizures  
  • Lorazepam
    (Status epilepticus)

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    Formulary
    Green
    Injection

  • FIRST CHOICE for inpatient status epilepticus if IV access possible

     
  • Diazepam
    (Status epilepticus)

    View adult BNF  View SPC online  Track Changes
    Formulary
    Green
    Injection (emulsion), Rectal tubes

  • Injection - Status epilepticus in hospital if IV lorazepam or buccal midazolam (Epistatus) not available
  • Rectal tubes - Status epilepticus in the community if buccal midazolam (Epistatus) not available

  •  
    Phenytoin
    (IV)

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    Formulary
    Red
    Injection

  • For management of status epilepticus if required after initial treatment with benzodiazepines
  • Give by slow intravenous injection or infusion with ECG and blood pressure monitoring
  • Intramuscular injection of phenytoin is not recommended

    Link  Phenytoin Prescribing and Monitoring Guideline
    Link  Tayside Therapeutic Drug Monitoring guidance  
  • Sodium Valproate
    (IV)

    View adult BNF  View SPC online  Track Changes
    Formulary
    Red
    Injection

  • After initial treatment in status epilepticus [off-label] if ECG monitoring or phenytoin not available.

    Link  Tayside Prescriber Issue No 142 - Valproate and Risk of Abnormal Pregnancy Outcomes, June 2016  
  • Levetiracetam
    (IV)

    View adult BNF  View SPC online  Track Changes
    Formulary
    Red
    Concentrate for intravenous infusion

  • Third line after Phenytoin IV or Sodium Valproate IV for status epilepticus [off-label]
     
  •  ....
     Non Formulary Items
    Clonazepam


    View adult BNF  View SPC online  Track Changes
    Non Formulary Tablets, Oral solution

     
    Gabapentin
    (Epilepsy)


    View adult BNF  View SPC online  Track Changes
    Non Formulary Capsules
     
    Controlled Drug  Midazolam (Buccolam)


    View adult BNF  View SPC online  Track Changes
    Non Formulary Oromucosal solution

  • Buccolam brand not recommended in Tayside - use Epistatus see Tayside Prescriber 133 May 2014
     
  • Pregabalin
    (Epilepsy)


    View adult BNF  View SPC online  Track Changes
    Non Formulary Capsules
     
    Primidone


    View adult BNF  View SPC online  Track Changes
    Non Formulary Previously marketed as Mysoline

  • Note: primidone is a hepatic enzyme inducer, and reduces the effectiveness of hormonal contraceptives - see advice above
     
  • Retigabine


    View adult BNF  View SPC online  Track Changes
    Non Formulary Tablets

  • Manufacturers are discontinuing, will no longer be commercially available after June 2017

    Link  MHRA Drug Safety Update - Retigabine (Trobalt): indication restricted to last-line use and new monitoring requirements, July 2013  
  • Rufinamide (Inovelon)


    View adult BNF  View SPC online  Track Changes
    Non Formulary Tablets, Oral suspension

  • Note: rufinamide is a hepatic enzyme inducer, and reduces the effectiveness of hormonal contraceptives - see advice above
     
  •   
    Key
    note Notes First Choice Item First Choice item
    Section Title Section Title (top level) Non Formulary Item Non Formulary section
    Section Title Section Title (sub level)
    Cytotoxic Drug
    Cytotoxic Drug
    Restricted Drug
    Restricted Drug
    CD
    Controlled Drug
    Unlicensed Drug
    Unlicensed
    High Cost Medicine
    High Cost Medicine
    click to search medicines.org.uk
    Link to SPCs
    click to search medicines.org.uk
    Link to adult BNF
    Track Changes
    Display tracking information
    click to search medicines.org.uk
    Cancer Drugs Fund
    Cancer Drugs Fund
       

     

    Traffic Light Status Information

    Status Description
      Green   General Use. May be initiated by primary or secondary care. Suitable for non specialist prescribing.  
      Amber   Can be prescribed in General Practice under the direction of a Specialist  
      Red   To be prescribed by Hospital Specialists Only  
      Black   SMC not accepted. SMC not recommended medicines must go through Individual Patient Treatment Requests (IPTRs) as outlined in the NHS Tayside IPTR policy  
      Grey   Medicines which NHS Tayside ADTC does not recommend for use at present due to limited clinical and/or cost effective data  

    netFormulary