Antiepileptic drugs

1. Choosing an Antiepileptic Drug (AED) for Sudden Seizures in Pediatrics
Acute Seizure Management (e.g., status epilepticus, prolonged seizures):

• First-line (benzodiazepines):
  • Lorazepam IV: preferred due to longer duration.
  • Diazepam IV or rectal: commonly used in emergencies or at home.
  • Midazolam IM, buccal, or intranasal: ideal when IV access is not available.

Second-line AEDs (if seizure persists after benzodiazepine):

• Levetiracetam IV (40–60 mg/kg, max 4,500 mg): well-tolerated, minimal interactions.
• Valproate IV (20–40 mg/kg): effective in generalized seizures, avoid in liver disease or <2 years.
• Phenytoin IV (15–20 mg PE/kg): effective for focal seizures, monitor cardiac status.

Note: Choose based on seizure type, age, comorbidities, and prior AED exposure.

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2. Choosing Long-Term AED Therapy (Post-Acute Phase)
Match AED to seizure type:

Seizure Type
First-line AEDs

Focal
Carbamazepine, Oxcarbazepine, Levetiracetam

Generalized tonic-clonic
Valproate, Levetiracetam, Lamotrigine

Absence
Ethosuximide, Valproate

Myoclonic
Valproate, Levetiracetam

Infantile spasms
ACTH, Vigabatrin

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3. When to Increase Dose vs. Add Another AED
A. Increase the dose if:

• Seizure control is partial.
• The child is tolerating the current AED without side effects.
• Serum level is below therapeutic range (if monitoring is available).
• There’s evidence that a higher dose may improve efficacy.

B. Add (combine) another AED if:

• Seizures are not controlled at maximum tolerated dose of first AED.
• There’s a mixed seizure type or epilepsy syndrome that may respond to polytherapy.
• First AED caused partial response and combination therapy may enhance efficacy.

Principles of combination therapy:

• Use AEDs with different mechanisms of action.
• Avoid overlapping side effects.
• Monitor closely for drug-drug interactions and cumulative toxicity.