Acth

Valproate

Lennox-Gastaut syndrome Valproic acid

Lamotrigine

Lamotrigine

Primidone

Levetirazetam

Lamotrigine

Primidone

Topiramate

Clobazam

Lamotrigine Clobazam Topiramate Felbamate hematotoxic adverse events, and vigabatrin leads to irreversible visual field constriction in 30% of patients.

An important feature in the clinical use of the firstline treatments is therapeutic drug monitoring (TDM). This should not be done as a routine procedure, but it may be useful in certain circumstances (e.g., to detect noncompliance and to explore changes in pharmaco-

kinetics). There are significant interindividual variations in the relationship between drug levels and clinical side effects. Therefore, the measurement of serum concentrations should not be used for the optimization of treatment (with few exceptions); decisions to alter dosages should be based on efficacy and tolerability of AEDs. For appropriate agents, indications for TDM may include drug initiation or dose change, investigation of the absence of or change in therapeutic response, investigation of suspected toxicity, and situations in which pharmacokinetics may change such as during pregnancy and related to renal or hepatic disease. Sampling should occur once steady state has been achieved, four to six half-lives after treatment has been modified or introduced. TDM is particularly important for phenytoin because its hepatic metabolism is saturable and therefore a small increase in dose can result in a disproportionate and unpredictable increase in serum concentration.

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