Table 1.

Anti-seizure medications

ASM	FDA approval for DEE-SSW	Common adverse reactions	Contra-indications	Lab monitoring	Special considerations	Notable interactions
Brivaracetam	No	Psychiatric disturbance Sedation Dizziness	Hypersensitivity to brivaracetam or component of formulation	Baseline CBC with differential Liver function Renal function Assessment for depression and suicidality	Consider if LEV was effective but had to discontinue due to behavioral side effects	None
Cenobamate	No	Maculopapular rash DRESS (drug reaction with eosinophilia and systemic symptoms) Shortened QTc interval Fatigue Dizziness	Familial short QT syndrome Hypersensitivity to cenobamate or component of formulation	Liver function Potassium as indicated Assessment for depression and suicidality	None	Caution with additional sodium channel blockers due to additive side effects and arrhythmia risk Moderately inhibits CYP2C19 (clobazam levels increased)
Clobazam	Yes	Drowsiness Drooling Aggressive behavior Irritability	Hypersensitivity to clobazam or component of formulation	CBC Liver function Renal function Assessment for depression and suicidality	Metabolized by CYP2C19 and CYP3A4	Levels may be increased with concomitant epidiolex, felbamate, cenobamate
Epidiolex	Yes	Weight loss Decreased appetite Diarrhea Vomiting	Hypersensitivity to epidiolex or component of formulation	Liver function testing at baseline, 1 month, 3 months, 6 months of initiation. Baseline CBC Assessment for depression/suicidality	Risk of transaminitis Inhibits CYP2C19	May increase clobazam levels
Felbamate	Yes	Drowsiness Weight loss	Hypersensitivity to felbamate, carbamates, history of blood dyscrasia or hepatic dysfunction	CBC with diff Reticulocyte count Liver function At baseline then every 2 weeks for the first month, once monthly for 3 months, then can gradually decrease frequency	Black box warning for aplastic anemia and liver failure Inhibits 2C19 (weak)	May increase clobazam levels
Fenfluramine	Yes	Elevated blood pressure Pulmonary hypertension Serotonin syndrome Valvular heart disease Weight loss CNS depression	Hypersensitivity to fenfluramine or component of formulation Concomitant use within 14 days of a monoamine oxidase inhibitor	None	REMs program, baseline echocardiogram and every 6 months required	Clobazam may increase levels; limit dose when used in conjunction with stiripentol and clobazam
Lamotrigine	Yes	Aseptic meningitis Blood dyscrasias Hypersensitivity reactions	Hypersensitivity to lamotrigine or component of formulation	EKG in patients with known cardiac disease or major risk factors Consider CBC and renal and hepatic function testing	Slow initial titration due to Stevens Johnson risk	Valproate inhibits metabolism, decrease dose by ½ when adding concomitant VPA
Levetiracetam	No	Behavioral problems and psychotic symptoms Drowsiness Delayed Hypersensitivity reactions Elevated blood pressure	Hypersensitivity to levetiracetam or component of formulation	Psychiatric and behavioral disturbance Renal function CBC Diastolic blood pressure in children < 4 years	None	None
Perampanel	No	Dizziness Aggression Vertigo Drowsiness	Hypersensitivity to perampanel or component of formulation	Renal function Hepatic function Assess for psychiatric disturbance	Boxed warning for worsening of aggression, anger, homicidal ideation, within the first 6 weeks with or without prior psychiatric history	None
Rufinamide	Yes	Shortened QT interval Nausea Dizziness Drowsiness Headache	Familial short QT syndrome Hypersensitivity to rufinamide or component of formulation	CBC Signs and symptoms of suicidality Consider EKG with concurrent medications which can shorten QT interval	None	None
Topiramate	Yes	Cognitive dysfunction Metabolic acidosis Nephrolithiasis Ocular effects Oligohidrosis Weight loss	Hypersensitivity to topiramate or component of formulation	Electrolytes Ammonia in patients with unexplained lethargy Intraocular pressure Kidney stones	None	None
Valproate	No	Alopecia Abdominal pain Thrombocytopenia Dizziness	Hypersensitivity to valproate or component of formulation Hepatic disease or impairment Urea cycle disorders Blood dyscrasias	Liver enzymes Ammonia with mental status change CBC Lipase with persistent vomiting	Avoid use in women of child-bearing age if possible	Inhibits metabolism of lamotrigine
Zonisamide	No	Anorexia Dizziness Drowsiness	Hypersensitivity to zonisamide, sulfonamides, or component of formulation	Electrolytes Ammonia in patients with unexplained lethargy	None