Carbamazepine adjunctive therapy

Adjunctive therapy For dosing guidelines below, enzyme-inducing antiepileptic drugs (ElAEDs) include phenytoin, carbamazepine, phenobarbital, and primidone. Patients 2 to 12 years of age ... 

Conversion from adjunctive therapy with AEDs other than carbamazepine, phenytoin, phenobarbital, primidone, or valproate to monotherapy with lamothgine No specific dosing guidelines can be provided for conversion to monotherapy with lamothgine with AEDs other than carbamazepine, phenobarbital, phenytoin, primidone, or valproate. 

Concomitant therapy On occasion, the addition of topiramate to phenytoin may require an adjustment of the dose of phenytoin to achieve optimal clinical outcome. The addition or withdrawal of phenytoin and/or carbamazepine during adjunctive therapy with topiramate may require adjustment of the dose of topiramate. 

The cognitive effects of topiramate and valproate as adjunctive therapy to carbamazepine have been compared in 53 patients (637). Topiramate was given in an initial dose of 25 mg and increased weekly by 25 mg/day increments to a minimum of 200 mg/day. Cognition was significantly worsened by topiramate and improved by valproate. Gradual introduction of topiramate reduced the extent of cognitive impairment. 

I Place in Therapy. Oxcarbazepine is indicated for use as monotherapy or adjunctive therapy in the treatment of partial seizures in adults and as monotherapy and adjunctive therapy in the treatment of partial seizures in patients as young as 4 years of age with epilepsy. It is also a potential first-fine drug for patients with primary generalized convulsive seizures. Oxcarbazepine may be effective in patients not demonstrating a response to carbamazepine. 

Carbamazepine is useful in the prophylaxis and therapy of partial seizures and psychomotor seizures. It is also useful in the therapy of trigeminal neuralgia, and as adjunct therapy in the treatment of manic-depressive disorders. 

The carbamazepine molecule shares structural homology with that of the tricyclic antidepressants, and has weak antidepressant activity. The depression of cortical excitability, due to sodium blockade, also makes it useful as adjunct therapy in the treatment of acute mania. 

Carbamazepine (CBZ Tegretol) (Fig. 20.6) was approved by the U.S. FDA in 1968, and it is presently indicated as initial or adjunct therapy for complex partial, tonic-clonic, and mixed-type seizures. It is one of the two safest and most effective older AEDs for these seizure types (phenytoin is the other) and is chosen for monotherapy because of its high effectiveness and relatively low incidence of side effects (40). Its tricyclic structure resembles that of the psychoactive drugs imipramine, chlorpromazine, and maprotiline and also... 

Oxcarbazepine (Trileptal ) is the 10-keto analogue of carbamazepine (Fig. 20.6). It is indicated as monotherapy or adjunctive therapy for partial seizures in adults with epilepsy, as monotherapy for the treatment of partial seizures in children 4 years of age or older, and as adjunct therapy in children 2 to 4 years of age. 

Carbamazepine (CBZ) is EDA approved for the treatment of monotherapy and adjunctive therapy of partial and generalized seizures. CBZ is very effective in the treatment of generalized tonic-clonic and partial seizures, but is not effective against myoclonic and absence seizures. ... 

Pharmacotherapy is the cornerstone of acute and maintenance treatment of bipolar disorder. Mood-stabilizing drugs are the usual first-choice treatments and include lithium, divalproex, carbamazepine, and lamotrigine. Atypical antipsychotics other than clozapine are also approved for treatment of acute mania. Lithium, lamotrigine, olanzapine, and aripiprazole are approved for maintenance therapy. Drugs used with less research support and without Food and Drug Administration (FDA) approval include topiramate and oxcarbazepine. Benzodiazepines are used adjunctively for mania. 

Again there are relatively few studies that have investigated the use of carbamazepine in maintenance therapy. The results of the studies published suggest that carbamazepine is not as effective as lithium or divalproex. In the controlled studies of carbamazepine, the majority of patients required adjunctive treatment to prevent a breakthrough for the manic or depressive symptoms. 

At this time, the preferred first-line drug therapy for ADHD is either methylphenidate, dexmethylphenidate, mixed amphetamine salts, or dextroamphetamine. Atomoxetine, bupropion, or TCAs are good options for those umesponsive to or unable to tolerate stimulants. Clonidine and guanfacine are third-line options or adjuncts that require careful cardiovascular monitoring. Mood stabilizers (e.g., lithium, divalproex, and carbamazepine) and atypical antipsychotics are adjuncts for control of aggression or comorbid bipolar disorder. Other agents require further investigation before their status in the treatment of ADHD can be fuUy determined. 

C. Clinical Use Lithium carbonate is used in the treatment of bipolar affective disorder (manic-depressive disease). Maintenance therapy with lithium decreases manic behavior and reduces both the frequency and the magnitude of mood swings. Drug therapy with neuroleptics or benzodiazepines may also be required at the initiation of lithium treatment. Antidepressant drugs may be required adjunctively during maintenance. Alternative drugs of value in bipolar affective disorder include carbamazepine, clonazepam, gabapentin, and valproic acid. 

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