Choosing antiseizure YOUNG EPILEPSY medication SECTION

Based on Asadi-Pooya, AA, Beniczky, S, Rubboli, G, Sperling, MR, Rampp, S, Perucca, E. A pragmatic algorithm to select appropriate antiseizure medications in patients with epilepsy. Epilepsia. 2020; 61: 1668– 1677; available online as EpiPick tool

How to 1 Select a seizure 2Up- or downgrade 3 Select the type and see how the medications medication use it medications are based on modifiers ranked first ranked (see the back side)

Type First level Second level Third level

LEV, ZNS, ACT, Absence ETS, VPA LTG CLB, CLN

TPM, ZNS Myoclonic CLN, VPA, LEV CLB PB, NTR

OXC, CLB, ZNS, LCM, TMP, PB, Prim. GTC VPA LTG, LEV PER, PHT, CBZ, BRV

CLN, LTG, ZNS, Prim. GTC+ CLB, TPM, PB, VPA LEV myoclonic PER, PHT, LCS, BRV

Prim. GTC + TPM, ZNS, VPA LTG, LEV absence CLB

Prim. GTC + TPM, ZNS, myoclonic + VPA LTG, LEV CLB, CLN absence

Myoclonic + TPM, ZNS, VPA, ETS LTG, LEV absence CLB, CLN

LEV, CBZ, LTG TPM, VPA, PER, CLB, PB, Focal OXC, ESL, LCM PHT, BRV, ZNS GBP, PGB

VPA, PER, PHT, Unknown + LEV, CBZ, LTG BRV, ZNS, PB, GBP, PGB age ≥ 21 OXC, ESL, LCM TPM, CLB

Unknown + CLB, CBZ, PER, VPA, LTG, LEV PB, TPM, ZNS age < 21 ESL, OXC, LCM

Abbreviations: ACT, acetazolamide; BRV, brivaracetam; CBZ, carbamazepine; CLB, clobazam; CLN, clonazepam; ESL, eslicarbazepine acetate; ETS, ethosuximide; GBP, gabapentin; LCM, lacosamide; LEV, levetiracetam; LTG, lamotrigine; NTR, nitrazepam; OXC, oxcarbazepine; PB, phenobarbital; PER, perampanel; PGB, pregabalin; PHT, phenytoin; TPM, topiramate; VPA, valproic acid; ZNS, zonisamide; Prim. GTC; primary generalized tonic-clonic

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@yesILAE @yesILAE @yes_ILAE Premenopausal women Oral contraceptive intake Focal seizures: discard PER, TPM VPA GTCS: 2nd level downgrade by one level Other types: ESL, CBZ, OXC, PB, PHT 3rd choice downgrade by two levels LTG LTG, LEV GTCS: 1st choice Estrogen reduces LTG levels; LTG moderately reduces levonorgestrel levels Age > 65 years

GBP, LCM, upgrade by Bleeding disorders LEV, LTG one level VPA Generalized Neutropenia downgrade by one level Focal or unknown downgrade by downgrade by two levels CBZ, PHT one level

Co-medications Diabetes mellitus (except contraceptives) downgrade by CBZ, PER, CBZ, PB, downgrade by one level PHT, VPA PHT one level

Focal or Hx of irritability BRV, GBP, LCM, unknown: LEV, LTG, upgrade by downgrade by LEV, PER, PER, ZNS one level PB, TPM one level Generalized: ETS, LCM, LEV, upgrade by LTG, PER, ZNS one level Migraine

upgrade by TPM, VPA one level Obesity GBP, PGB downgrade by one level Renal stones VPA Generalized ACT, TPM, downgrade by downgrade by one level ZNS one level Focal or unknown downgrade by two levels

Brain tumor requiring chemo-/radiotherapy Allergy to any drug ESL, CBZ, LTG, ESL, CBZ, PB, OXC, PHT downgrade by downgrade by two levels OXC, PB, PHT, ZNS one level

Hepatic GBP, LCM, LEV VPA failure upgrade by one level downgrade by two levels

CLB, ETS, LTG, Renal All other drugs CBZ, PHT downgrade by one level failure upgrade by one level

LTG CLB, CNZ, LEV, NTZ, PB Depression upgrade by one level downgrade by one level

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