SEIZURES -WHAT IS YOUR CHOICE?

Pharmacological treatment of newly diagnosed generalized tonic–clonic (GTC) seizures

First-line treatment in children, young people and adults with newly diagnosed GTC seizures

 Offer sodium valproate as first-line treatment to children, young people and adults with newly diagnosed GTC seizures. Be aware of teratogenic risks of sodium valproate (see recommendation 1.9.1.10). [new 2012]

 Offer lamotrigine if sodium valproate is unsuitable. If the person has myoclonic seizures or is suspected of having juvenile myoclonic epilepsy (JME), be aware that lamotrigine may exacerbate myoclonic seizures. [new 2012]

 Consider carbamazepine and oxcarbazepine[14] but be aware of the risk of exacerbating myoclonic or absence seizures. [new 2012]

Adjunctive treatment in children, young people and adults with GTC seizures

 Offer clobazam[14], lamotrigine, levetiracetam, sodium valproate or topiramate as adjunctive treatment to children, young people and adults with GTC seizures if first-line treatments (see recommendations 1.9.4.1, 1.9.4.2 and 1.9.4.3) are ineffective or not tolerated. Be aware of teratogenic risks of sodium valproate (see recommendation 1.9.1.10). [new 2012]

 If there are absence or myoclonic seizures, or if JME is suspected, do not offer carbamazepine, gabapentin, oxcarbazepine, phenytoin, pregabalin, tiagabineor vigabatrin. [new 2012]

First-line treatment in children, young people and adults with newly diagnosed focal seizures

 Offer carbamazepine or lamotrigine as first-line treatment to children, young people and adults with newly diagnosed focal seizures. [new 2012]

  Offer levetiracetam, oxcarbazepine or sodium valproate  if carbamazepine and lamotrigine are unsuitable or not tolerated. If the first AED tried is ineffective, offer an alternative from these five AEDs. Be aware of the teratogenic risks of sodium valproate (see recommendation 1.9.1.10). [new 2012]

Consider adjunctive treatment if a second well-tolerated AED is ineffective (see recommendations 1.9.3.1 and 1.9.3.2). [new 2012]

Adjunctive treatment in children, young people and adults with refractory focal seizures

 Offer carbamazepine, clobazam[14], gabapentin[14], lamotrigine, levetiracetam, oxcarbazepine, sodium valproate or topiramate as adjunctive treatment to children, young people and adults with focal seizures if first-line treatments (see recommendations 1.9.3.1 and 1.9.3.2) are ineffective or not tolerated. Be aware of teratogenic risks of sodium valproate (see recommendation 1.9.1.10). [new 2012]

If adjunctive treatment (see recommendation 1.9.3.4) is ineffective or not tolerated, discuss with, or refer to, a tertiary epilepsy specialist. Other AEDs that may be considered by the tertiary epilepsy specialist are eslicarbazepine acetate[14], lacosamide, phenobarbital, phenytoin, pregabalin[14], tiagabine vigabatrin and zonisamide[14].

Carefully consider the risk–benefit ratio when using vigabatrin because of the risk of an irreversible effect on visual fields. [new 2012]

Pharmacological treatment of absence seizures

First-line treatment in children, young people and adults with absence seizures

 Offer ethosuximide or sodium valproate as first-line treatment to children, young people and adults with absence seizures. If there is a high risk of GTC seizures, offer sodium valproate first, unless it is unsuitable. Be aware of teratogenic risks of sodium valproate (see recommendation 1.9.1.10). [new 2012]

Offer lamotrigine[14] if ethosuximide and sodium valproate are unsuitable, ineffective or not tolerated. [new 2012]

Adjunctive treatment in children, young people and adults with absence seizures

If two first-line AEDs (see recommendations 1.9.5.1 and 1.9.5.2) are ineffective in children, young people and adults with absence seizures, consider a combination of two of these three AEDs as adjunctive treatment: ethosuximide, lamotrigine[14] or sodium valproate. Be aware of teratogenic risks of sodium valproate (see recommendation 1.9.1.10). [new 2012]

 If adjunctive treatment (see recommendation 1.9.5.3) is ineffective or not tolerated, discuss with, or refer to, a tertiary epilepsy specialist and consider clobazam[14], clonazepam, levetiracetam[14], topiramate[14] or zonisamide[14]. [new 2012]

 Do not offer carbamazepine, gabapentin, oxcarbazepine, phenytoin, pregabalin, tiagabine or vigabatrin. [new 2012]

 Pharmacological treatment of myoclonic seizures

First-line treatment in children, young people and adults with myoclonic seizures

 Offer sodium valproate as first-line treatment to children, young people and adults with newly diagnosed myoclonic seizures, unless it is unsuitable. Be aware of teratogenic risks of sodium valproate (see recommendation 1.9.1.10).[new 2012]

Consider levetiracetam[14] or topiramate[14] if sodium valproate is unsuitable or not tolerated. Be aware that topiramate has a less favourable side-effect profile than levetiracetam and sodium valproate. [new 2012]

Adjunctive treatment in children, young people and adults with myoclonic seizures 1.9.6.3 Offer levetiracetam, sodium valproate or topiramate[14] as adjunctive treatment to children, young people and adults with myoclonic seizures if first-line treatments (see recommendations 1.9.6.1 and 1.9.6.2) are ineffective or not tolerated. Be aware of teratogenic risks of sodium valproate (see recommendation 1.9.1.10). [new 2012]

If adjunctive treatment (see recommendation 1.9.6.3) is ineffective or not tolerated, discuss with, or refer to, a tertiary epilepsy specialist and consider clobazam clonazepam, piracetam or zonisamide[14]. [new 2012]

 Do not offer carbamazepine, gabapentin, oxcarbazepine, phenytoin, pregabalin, tiagabine or vigabatrin. [new 2012]