Valproate clonazepam

The addition of clonazepam to sodium valproate increased the unwanted effects (drowsiness, absence status) in 9 out of 12 paediatric and adolescent patients. An analysis of the clonazepam-valproate interaction in 317 epileptic patients found that concurrent use increased clonazepam clearance by 14% and decreased valproate clearance by 17.9%. ... 

Myoclonic Not mentioned Lamotrigine Valproate Valproate Topiramate (children with severe myoclonic epilepsy of infancy) Second-line Clobazam6 Clonazepam Lamotrigine Levetiracetam Piracetam6 Topiramate... 

First, optimize current mood stabilizer or initiate mood-stabilizing medication lithium,0 valproate,0 or carba-mazepine0 Consider adding a benzodiazepine (lorazepam or clonazepam) for short-term adjunctive treatment of agitation or insomnia if needed Alternative medication treatment options carbam-azepine0 if patient does not respond or tolerate, consider atypical antipsychotic (e.g., olanzapine, quetiapine, risperidone) or oxcarbazepine. 

Support is scant for the efficacy of anticonvulsant agents in the treatment of OCD (Jenike 1990 Joffe and Swinson 1987). If there is a role for carbamazepine in OCD, it may be in patients with clinical or electroen-cephalographic evidence of a seizure disorder (Jenike and Brotman 1984 Khanna 1988). The anti-OC efficacy of combined SRI-carbamazepine treatment has not been adequately studied. Sodium valproate was found ineffective in two cases of OCD (McElroy and Pope 1988 McElroy et al. 1987). However, one author has suggested that sodium valproate may be a useful pretreatment for patients with OCD who might otherwise tolerate SRIs poorly (Deltito 1994). The anticonvulsant clonazepam is discussed earlier in this chapter. 

It is a benzodiazepine useful in the treatment of petitmal epilepsy, myoclonic seizures and infantile spasms. It is used in the treatment of petitmal epilepsy not responding to ethosuximide and sodium valproate. Clonazepam and diazepam act by increasing the effectiveness of the inhibitory neurotransmitter GABA, within the central nervous system. 

Ontiveros A, Fontaine R. Sodium valproate and clonazepam for treatment-resistant panic disorder. J Psychiatr Neurosci 1992 17 78-80. 

Halman et al. (491) conducted a retrospective chart review on 11 patients who were HIV-positive and presented with an acute manic episode. Whereas the six patients with abnormal MRI findings demonstrated intolerance to standard drug treatment (i.e., lithium, conventional neuroleptics), all benefited from a trial with an anticonvulsant (e.g., valproate, CBZ, clonazepam). 

At least three drugs are effective against absence seizures. Two are nonsedating and therefore preferred ethosuximide and valproate. Clonazepam is also highly effective but has disadvantages of dose-related adverse effects and development of tolerance. Lamotrigine and topiramate may also be useful. 

Specific myoclonic syndromes are usually treated with valproate an intravenous formulation can be used acutely if needed. It is nonsedating and can be dramatically effective. Other patients respond to clonazepam, nitrazepam, or other benzodiazepines, although high doses may be necessary, with accompanying drowsiness. Zonisamide and levetiracetam may be useful. Another specific myoclonic syndrome, juvenile myoclonic epilepsy, can be aggravated by phenytoin or carbamazepine valproate is the drug of choice followed by lamotrigine and topiramate. 

For simple and complex partial seizures and secondary generalized tonic-clonic seizures, the first line drugs are - carbamazepine, valproate and phenytoin. Second line drugs include - acetazolamide, clobazam, clonazepam, ethosuximide, felbamate, gabapentin, lamotrigine, levetiracetam, oxacarbamazepine, primidone, tiagabine, topiramate and vigabactin. 

For generalized absence seizures, first line treatment is with valproate or ethosuximide and second line treatment with acetazolamide, clobazam, clonazepam, lamotrigine, phenobarbitone and primidone. 

Myoclonic seizures are best treated with valproate but, as a second choice, with clobazam, clonazepam, ethosuximide, lamotrigine, phenobarbitone, piracetam or primidone. 

Carbamazepine is a hepatic microsomal enzyme inducer and therefore will lower the serum concentration of a wide variety of drugs given concurrently. These include the antiepileptic drugs phenytoin, primidone, valproate, ethosuximide and clonazepam. In addition, carbamazepine can compromise the therapeutic effects of oral contraceptives, oral anticoagulants, beta-blockers, haloperidol and theophylline. 

Carbamazepine + phenytoin, tricyclic antidepressants, typical neuroleptics, valproate, clonazepam, warfarin, nefazodone and propoxyphene —> reduced plasma concentration of carbamazepine due to increased metabolism. 

There is little evidence that lithium is superior to other drugs with sedative actions for the treatment of acute mania. Benzodiazepines, neuroleptics and anticonvulsants have all been tried in mania and none have been found to be inferior to lithium. Two small studies of clonazepam in mania found it was superior to lithium (Chouinard 1988 Chouinard, Young, Annable 1983). All new- and old-generation neuroleptics have been found to be more effective than placebo (Perlis et al. 2006). Comparisons of lithium with the sedative anticonvulsants carbamazepine and sodium valproate show similar effects (Bowden et al. 1994 Freeman et al. 1992 Lerer et al. 1987 Small et al. 1991). 

The addition of risperidone 10 mg/day over 2 months to valproate and clonazepam in a 40-year-old woman provoked marked edema in the legs and moderate edema in the arms (276). The authors considered that this was a possible interaction, since edema has not been reported with either of these drugs separately. 

A 2-year old girl with epilepsy and dyskinetic cerebral palsy due to kemicterus, who was taking carbamaze-pine and valproate, was also given clonazepam 0.05 mg/day and 3 days later developed urinary retention, which did not improve with antibiotic treatment (10). A urine sample obtained by catheterization was sterile. Urinary retention persisted for 10 days, requiring repeated catheterization, but resolved after clonazepam was withdrawn. She was symptom free for the next 6 months. 

The effects of concomitant carbamazepine, phenytoin, sodium valproate, and zonisamide on the steady-state serum concentrations of clonazepam have been investigated in 51 epileptic in-patients under 20 years of age (14). Serum concentrations of clonazepam correlated positively with the dose of clonazepam and negatively with the doses of carbamazepine and valproic acid, but not with phenytoin or zonisamide. These results confirm that as the oral doses of carbamazepine and sodium valproate increase, the serum concentration of clonazepam falls, but there is no interaction with either phenytoin or zonisamide. In the case of carbamazepine the mechanism of action is thought to be enzyme induction, increasing the metabolism of clonazepam. It is not known what the mechanism is with sodium valproate. In patients with epilepsy, the co-administration of either sodium valproate or carbamazepine will reduce the serum concentration of clonazepam and increase the risk of a seizure. When... 

First two or three dmg combinations lithiurtf or valproate plus a benzodiazepine (lorazepam or clonazepam) for short-tenn adjunctive treatment of... 

Use of clonazepam with valproate may cause absence status... 

Individual drugs carbamazepine, phenytoin, sodium valproate, lamotrigine, vigabatrin, gabapentin, clonazepam, topiramate, levetiracetam. 

Anticonvulsants. Carbamazepine, phenobarbital and primidone accelerate warfarin metabolism (enzyme induction) the effect of phenytoin is variable. Clonazepam and sodium valproate are safe. 

Valproate, clonazepam, or clobazam may be safer alternatives in patients who have had a rash from aromatic anticonvulsants. However, in a 41-year-old man a fixed drug eruption that occurred after phenytoin and carbamazepine also occurred after valproate (SEDA-22, 83). 

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